NFPA Journal - Winter 2024 - 44

an up-to-date emergency plan for Grenfell Tower,
as well as the challenges faced by the London Fire
Brigade, especially its leadership, in its ability to
effectively respond to fires in high-rise buildings and
manage a high volume of emergency calls:
Although the TMO had no obligation to produce
a general evacuation plan, its Emergency Plan for
Grenfell Tower was out of date and incomplete and
did not reflect the changes brought about by the
refurbishment. The TMO was well aware of that
fact following a fire at Adair Tower in October 2015
but failed to address it. The absence of fire action
notices in the tower was a prominent subject of
complaints by residents and led to the issue of a
Deficiency Notice in November 2016.
The Grenfell Tower fire revealed the importance of
ensuring that the responsible person under the Fire
Safety Order collects sufficient information about
any vulnerable occupants to enable [their personal
emergency evacuation plan] to be prepared, when
appropriate, and, in the event of a fire, appropriate
measures to be taken to assist their escape. The
TMO did take some steps to gather information
of that kind, both before and during the refurbishment,
but its data systems were not properly
coordinated. Such information as was collected was
not always used to revise its records, with the result
that the spreadsheet available on the night of the
fire was incomplete. The TMO's failure to collect
such information amounted to a basic neglect of its
obligations in relation to fire safety.
The Lakanal House fire in July 2009 should have
alerted the LFB to the shortcomings in its ability
to fight fires in high-rise buildings that revealed
themselves once more at Grenfell Tower on the
night of 14 June 2017. Those shortcomings could
have been made good if the LFB had been more
effectively managed and led. In particular, it
should have responded more effectively to its
experience at Lakanal House and made better
use of the knowledge it had gained of the dangers
posed by modern materials and methods of
construction. Importantly, it failed to ensure that
in the years immediately preceding the Grenfell
Tower fire regular training of a suitable kind
was provided to its control room operators on
handling many fire survival guidance calls concurrently
and on their duties more generally.
Senior managers at the LFB failed to take steps
to ensure that its arrangements for handling fire
survival calls reflected national guidance.
Those failures were attributable to a chronic lack
of effective management and leadership, combined
with an undue emphasis on process. Senior officers
were complacent about the operational efficiency
of the brigade and lacked the management skills to
44 | NFPA JOURNAL * WINTER 2024
Failures were compounded by
an entrenched but unfounded
assumption that the Building
Regulations were sufficient to
ensure that external wall fires
of the kind that were known
to have occurred in other
countries would not occur
in this country.
recognize the problems or the will to correct them.
Those managerial weaknesses were partly the result
of an historic failure to integrate the operational
departments and the departments responsible for
support functions, in particular the control room.
There was a tendency to treat problems of which
managers became aware as undeserving of change
or too difficult to resolve, even when they concerned
operational or public safety.
Those failures were compounded by an entrenched
but unfounded assumption that the Building Regulations
were sufficient to ensure that external wall
fires of the kind that were known to have occurred
in other countries would not occur in this country.
After the Lakanal House fire senior officers recognized
that compliance with the regulations could not
be guaranteed, but no one appears to have thought
that firefighters needed to be trained to recognize
and deal with the consequences.
The main failings on the part of the LFB that led to
the shortcomings identified in the Phase 1 report
included a failure to identify training needs combined
with a system for commissioning new training
packages that was cumbersome and slow. Incident
command training was poorly devised and was
not effectively delivered; inadequate provision was
made for refresher training and regular assessment.
The LFB failed to ensure that the knowledge of the
dangers presented by the increasing use of combustible
materials, in particular the risk of external fire
spread and the resulting loss of compartmentation,
held by some specialist officers was shared with the
wider organization and reflected in training, operational
policies and procedures. Firefighters were not
given proper training or guidance on how to carry
out inspections of complex buildings, and there were
no effective arrangements for sharing information
about risks posed by particular buildings. Internal
recommendations for improving the inspection of
high-rise residential buildings were not implemented.
The policy on high-rise firefighting did not reflect
national guidance, and senior management failed
to recognize that producing contingency plans for
NFPA Journal - Winter 2024

Table of Contents for the Digital Edition of NFPA Journal - Winter 2024
