Learning lessons from the Grenfell Tower Inquiry Report

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Learning lessons from the Grenfell Tower Fire Inquiry report In this article, Catherine Levin shares her analysis of the Grenfell Tower Inquiry Phase 1 report recommendations. She takes a look at how the experience of London Fire Brigade has lessons that apply to all fire and rescue services when it comes to policies, blue light cooperation and investment in equipment.

Words: Catherine Levin At risk of being overlooked in a week that could have seen the UK leave the European Union, the keenly anticipated and very much needed report from the Grenfell Tower Inquiry was granted the space it needed to cut through the noise of Brexit. Weighing in at over 4kg and over 800 pages long, the Grenfell Tower Inquiry Phase one report was published on 30 October 2019.

The report is divided into six parts and is written in the first person, providing a very personal tone to a report that bears Sir Martin Moore-Bick’s name. Starting with a broad introduction to the events of 14 June 2017, the report moves on to set out a forensic narrative account of the fire and the response to it. Sir Martin shares his conclusions about the origin and development of the fire as well as providing space for very moving tributes to those who died in the fire. Before looking ahead to phase 2 of the inquiry, he sets out his recommendations in detail and it is these that are the focus of this article.

Prior to the publication of the Grenfell Tower Inquiry Phase 1 report, the London Fire, Resilience and Emergency Planning Committee met to consider the Grenfell Tower Progress Report provided to them by the London Fire Commissioner, Dany Cotton.

“We are lobbying for major building regulation change and urgent research into ‘buildings that fail’ on fire safety, which leaves the national ‘stay put’ strategy no longer viable.”

The committee met again on 5 November to consider the recommendations in Sir Martin’s report. Dr Fiona Twycross AM and Deputy Mayor for Fire in London said at the start of the meeting, “We accept the report’s recommendations fully and unequivocally. We will work with the brigade, the trade unions and other stakeholders to make sure that those that apply to the London Fire Brigade are implemented and embedded as quickly as is possible.”

National level With both the Inquiry recommendations and the LFB progress report to hand, it is possible to get a view on

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how far the LFB has come and how much it aligns with Sir Martin’s thinking. While much of Sir Martin’s report is viewed through the lens of LFB, a lot is relevant to fire and rescue services across the country and needs to be considered at a national level.

Speaking in Parliament on publication day, Boris Johnson opened a debate on the Grenfell Tower fire. He said of Sir Martin Moore-Bick, “Led always by the facts, his recommendations are clear and numerous, and where there are failings to be highlighted, he does so without fear or favour.”

The recommendations are threaded through a detailed narrative that sets the scene and context for them. There are 46 recommendations but they are not all equal. They vary in terms of detail; some are granular and prescriptive, others are framed around a broad expectation of change. Given the sequencing of publication, the LFB progress report does not lend itself to a direct comparison to the Inquiry recommendations so there are gaps and areas where LFB has no locus.

It is not possible to go through all 46 recommendations in detail in the space available, so this article looks at three areas: the first relates to evacuation and the policy known as ‘stay put’; the second looks at emergency service cooperation; and the third looks at the fire escape hood.

‘Stay put’: an article of faith?

There is understandably considerable attention paid within the report to the subject of emergency calls, with a total of eight recommendations under this heading.

In the Control Room section of the report, Sir Martin writes, ‘In the case of the Grenfell Tower fire, about 120 calls were received from occupants in the building in addition to the many calls made by members of the public from outside. It is clear, therefore, that the number and frequency of 999 calls, and in particular of FSG calls properly so called, was wholly unprecedented, exceeding by many times the number received in connection with the Lakanal House fire, which itself was a major event.’

FSG is an acronym for Fire Survival Guidance. London Fire Brigade has a policy note PN790, which defines the term and sets out the procedures for staff, ‘A FSG call is a call received into control where the caller believes that they are unable to leave their premises due to the effects of fire, and where the control officer remains on the line providing appropriate advice. The call continues until either the caller is able to leave by their own means, is rescued by the Fire Brigade, or the telephone line is cleared.’

Sir Martin recommends changes to LFB’s policies, ‘To draw a clearer distinction between callers seeking advice and callers who believe they are trapped and need rescuing.’ He goes on to make recommendations

The Grenfell Tower Inquiry Phase one report was published on 30 October 2019.

in the areas of training, dealing with large numbers of FSG calls simultaneously, the recording of that information, and handle a change of advice and convey it to all callers.

It is this latter point that made the headlines on the day the report was published.

There is a recommendation to develop policies (and he does not say just LFB here) for managing a transition from ‘stay put’ to ‘get out’. Currently, the Government’s risk assessment guidance, known as GRA 3.2, states that a ‘stay put’ policy would be based on the concept of secure compartmentation of fires – meaning they shouldn’t spread beyond a flat in a high rise building, for example. But that was not the case at Grenfell Tower, as has now been well documented.

Sir Martin makes the point that the concept of fires staying inside compartments (mostly individual flats) is so ingrained in fire and rescue service planning assumptions that to move away from the management of the risk – one of which is to get those in nearby flats to ‘stay put’ because they are safer – is hard to fathom.

That is why he calls ‘stay put’ policy an article of faith.

The report states, ‘One could occasionally detect in the evidence of senior officers a reluctance to believe that a building could ever fail to comply with the Building Regulations. The evidence taken as a whole strongly suggests that the ‘stay put’ concept had become an article of faith within the LFB so powerful that to depart from it was to all intents and purposes unthinkable.’

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One look at the National Fire Chief Council’s website finds that the NFCC too has a clear position on ‘stay put’ for residents of purpose-built flats; it asserts that it is the correct advice where flats are built and maintained correctly. ‘A change to simultaneous evacuation should only be temporary until the risk has been removed.’ It provided updated guidance on this in May 2018.

Sir Martin is unflinching in his criticism of LFB on this point. ‘The fact that the Commissioner was compelled to ask the rhetorical question: “It’s all very well saying ‘Get everybody out’, but then how do you get them all out?” emphasises that the LFB had never itself sought to answer that question in its preparations and training and had not equipped itself to carry out a total evacuation of such a building.’

Responding to the Prime Minister’s statement about the Inquiry report, Jeremy Corbyn, the leader of the Opposition, said, “It is disgraceful that, two years on, there has still not been a major review or assessment of the ‘stay put’ policy. I echo the Prime Minister’s words when he said that it is an article of faith in dealing with high-rise block fires, but although it may be an article of faith, there clearly has to be a serious review and examination of that policy.”

This is in line with the statement by the London Fire Commissioner who said in response to the publication of the inquiry report, “We are lobbying for major building regulation change and urgent research into ‘buildings that fail’ on fire safety, which leaves the national ‘stay put’ strategy no longer viable.” This is in line with the LFB progress report, which struck a note of caution about the challenges ahead. It states, ‘The sector, including the Brigade recognises that any guidance would need to reflect that fire and rescue services cannot communicate with every individual, cannot readily check whether everyone has left their flat and the building without placing firefighters at significant risk; and will be dealing with both firefighting activity, to protect access

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and egress routes, and mass emergency evacuation via a means of escape not designed to facilitate the immediate evacuation of all residents.”

None of this is new to fire and rescue services. GRA 3.2 already had a requirement in it for, ‘An operational evacuation plan … in the event the ‘stay put’ policy becomes untenable’.

At the 5 November meeting there appeared to be a consensus about the need to develop new guidance on what Matt Wrack, General Secretary of the Fire Brigades Union (FBU), called ‘mass rescue’ as opposed to ‘evacuation’. The route to getting there is still the subject of debate, along with the funding to carry out the work, who should do it and how it is exercised to make sure it actually does the job. It is clear that this subject is going to run on for some considerable time.

Improving cooperation between the emergency services There are seven recommendations focused on cooperation between the emergency services; the first four of which are all about the Joint Doctrine.

The Joint Doctrine: the interoperability framework is guidance intended to improve the interoperability of the emergency services and other responder agencies. The Foreword notes, ‘We need to make sure that the ethos of ‘working together’ becomes embedded, not only within our own organisations at every level but within that of other responder agencies.’

Sir Martin is interested in the relationship between London Fire Brigade, the Metropolitan Police and the London Ambulance Service. Highlighting the significance of the Joint Doctrine, Sir Martin is perplexed by it, saying, ‘The Joint Doctrine is well-intentioned, but it is not an easy document to navigate or penetrate beyond the first few pages.’ He goes on, ‘I hope it is not unfair to say that it bears all the hallmarks of managerial conceptualism, designed to fulfil a statutory

requirement in a vacuum, and does not appear to be based on the experience of those who operate on the incident ground in the real world.’

He says that the Category 1 Responders (LFB, MPS, LAS and the London Borough of Kensington and Chelsea) did not fully adhere to the principles contained in the Joint Doctrine with the principle, common to all, being poor communication. The consequence of this was organisations working in isolation and in ignorance of what others were doing.

“We need to make sure that the ethos of ‘working together’ becomes embedded, not only within our own organisations at every level but within that of other responder agencies.”

Looking specifically at how and when the three emergency services declared a Major Incident, he finds that they all declared at different times and did not inform either of the others about it. In fact, the LFB declared a Major Incident more than half an hour after the MPS, with the LAS lagging half an hour behind that.

He goes into some detail about how and when METHANE messages were sent. By this he is referring to an acronym that sets out the common model for

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12 | ESTNEWS passing incident information between services and their control rooms. This appears in the Joint Doctrine and is well known by the emergency services through the work of the Joint Emergency Service Interoperability Principles or JESIP. The second edition, dated July 2016, is referenced in Sir Martin’s report. He recommends that it is amended in four areas to make it clear that: 1. Each emergency service must communicate the declaration of a Major Incident to all other Category 1 Responders as soon as possible 2. On the declaration of a Major Incident clear lines of communication must be established as soon as possible between the control rooms of the individual emergency services 3. A single point of contact should be designated within each control room to facilitate such communication 4. A ‘METHANE’ message should be sent as soon as possible by the emergency service declaring a Major Incident.

There are three other recommendations concerning emergency service cooperation.

The first appears to be support for introducing the Multi Agency Incident Transfer protocol but does not specifically mention it by name. MAIT, as it is more commonly known, provides a standard to communicate incident information between control rooms. Sir Martin recommends, ‘That steps be taken to investigate the compatibility of the LFB systems with those of the MPS and the LAS with a view to enabling all three emergency services’ systems to read each other’s messages.’

Emergency Services Times published a feature on control rooms in its February 2019 edition. This looked at the development of MAIT and described the aspiration for the emergency services to share and collaborate on a real time basis in one area but found that no one is using it, with the exception of a trial in Wales using an earlier version of the protocol. London Fire Brigade received £760,000 from the 2016 DCLG Fire Transformation Fund to implement data transfer between fire, ambulance and police control rooms to support joint incidents. The project is up and running but in terms of implementing MAIT in London, it is far from complete.

The second recommendation centres on the use of helicopters to provide footage from the incident ground to control rooms. The National Police Air Service (NPAS) provides air support to the 46 police forces of England and Wales from a national network of 14 bases.

The helicopters are capable of streaming live video from the air direct to emergency services vehicles or control rooms. The data stream is encrypted and protocols determine how this is done, including the use of different channels for transmitting data. On the night of the Grenfell Tower fire, the data stream from the helicopter did not default to the National Emergency Service user encryption but rather the police only encryption, which meant that the LFB control room and command units could not access the data stream.

Sir Martin explains that the NPAS crews were unaware they were using the wrong encryption keys. ‘It was not evident to the NPAS crews at the time because they had never received any training on the differences between the two systems. Accordingly, until the MPS provided the LFB with portable downlinks using the correct National Police user encryption, the firefighters could not view the images.’

The significance of this is described by Sir Martin, who suggests that had the LFB control room had access to

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the video images from the first NPAS helicopter that arrived at 0145 it would have provided valuable aerial views of all four sides of the tower.

He writes, ‘It is not clear whether that would have made any difference to the strategy which WM Dowden had adopted up to that point, but it might well have assisted both him and succeeding incident commanders. If nothing else, it might have enabled them to appreciate that the fire was not confined to the exterior of the building, as they appear to have believed, but had penetrated a large number of flats, with the result that the compartmentation of the building had completely failed. Their failure to appreciate that the fire had penetrated the interior of the building contributed to the delay in the decision to revoke the ‘stay put’ advice to residents. Seeing the visual images might also have brought forward the point at which the LFB declared a Major Incident.’

The third recommendation goes beyond the emergency services and includes all local authorities (and could extend to all those involved in local resilience forums) focusing on improving the collection of information about survivors and making it available more quickly to those wishing to make contact with them.

Fire escape hoods Sir Martin makes a very specific recommendation about equipment in his report. He focuses in on the fire escape hood. ‘That all fire and rescue services be equipped with smoke hoods to assist in the evacuation of occupants through smoke-filled exit routes.’

Evacuating residents through smoke filled environments is hazardous. Firefighters wear personal protective equipment and breathing apparatus but none of this is available to members of the public. For this reason, and in response to the learning from the Grenfell Tower fire, London Fire Brigade invested in fire escape hoods, distributing over 600 to its 102 fire stations from October 2018.

A fire escape hood provides a person with 15 minutes of clean, filtered air in a smoke filled environment. The tight seal around the hood protects against highly toxic fire-related gases.

The London Fire Brigade explanatory video shows a fire escape hood from Draeger. The Parat 5550 was specifically developed for fire rescue teams for use in victim rescue.

In February 2019, Kent Fire and Rescue Service introduced fire escape hoods, only the second fire and rescue service at that time to do so. Working collaboratively with LFB, Kent FRS rolled out fire escape hoods to all its whole-time and on-call fire appliances, with additional hoods carried by its support vehicles.

KFRS Chief Executive Ann Millington said, “We’re really pleased to have worked in partnership with our colleagues at London Fire Brigade, as well as the Fire Brigades Union, to progress this project and introduce smoke hoods as a standard part of the kit our crews carry. Having the hoods on our fire engines further enhances our ability to look after our customers and help keep them safe. Services across the UK have been following progress in this project and will be adopting this excellent practice.”

The cost of equipping every fire and rescue service with fire escape hoods is likely to be considerable if they are to be attached to all breathing apparatus sets regardless of whether a service has high rise high risk buildings in their area. It is a prime candidate for a national procurement and as Ann Millington leads for the National Fire Chiefs Council for procurement, Kent’s early adopter status makes this very likely to happen.

The Inquiry in numbers • £40.2m cost (up to March 2019) • 1 Inquiry Chairman • 52 members of Counsel, including 4 QCs • 16 experts

• 619 Core Participants • 123 days hearings • 140 witnesses • 500,000 documents received.

Running an inquiry of this scale is expensive so it was no surprise that when the costs were quietly published by the Inquiry team on 1 November that the headline figure was huge: £40.2m. This is for the period to end of March 2019.

The Inquiries Act 2005 and the Inquiry Rules 2006 set out the financial rules that any inquiry must follow.

The Inquiry divides the costs into two halves. The first is the cost of legal representation for the Bereaved, Survivors and Residents as well as the legal costs for the trade unions (FBU and FOA) the total cost for the period to end of March 2019 stood at £18.8m.

The second half is the costs of the Inquiry itself and its operations. The Inquiry costs are a mixture of things but the headlines include annual remuneration for Sir Martin Moore-Bick of around £220,000, which forms part of the overall bill of £5.1m for him and Counsel (that’s the QCs and all the lawyers for the Inquiry). This sits alongside a hefty bill for the Inquiry secretariat, accommodation and other operational costs of just over £9m.

With the Inquiry due to start Phase 2 hearings in the New Year, these costs will continue to rise and rise.

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