“There was no regular
training programme to keep them (the control room operators) up to speed with the sort of questions they should ask and how to respond,” said expert New Zealand witness, Brian Davey
Smoke billows from the ventilation grille at the north end of the 11th floor internal corridor as a consequence of a severe internal fire Davey says incident commanders didn’t understand their control room was advising occupants to stay put — he blames lack of training and poor communications procedure. “Even those control room operators who had been there for some time could only recall one training session a decade earlier. There was no regular training programme to keep them up to speed with the sort of questions they should ask and how to respond.” Command and no control And Davey says there were some serious command and control issues, particularly around the London Fire Brigade hand-over process which resulted in an inadequate number of appliances turning out. The arriving officer made “pumps four” when four engines were already on the way, then when queried only ordered another two, thereafter pumps were ordered in increments of two, three times over the next 20 minutes. Davey says the first officer should have got at least six more pumps on the road then ramped it up. In the end 18 pumps turned up but it was too late to have the necessary impact. “They failed NZ Security
to assess the extent of the situation quickly enough.” When a “type 5, aerial appliance” with 18 metre extension ladder and platform arrived in the first five minutes the operator refused to deploy, saying there was too much flaming debris. Half an hour later another unit went to work successfully in the same circumstances. “There was an issue around familiarity with the area of operation; if the first appliance operator could have found a way to deploy they could have improved access or at least put up a water curtain to extinguish the burning debris,” says Davey. The inquest was also critical of the hand over process. Procedures require a more senior officer to take command as an incident escalates and to be briefed on an action plan based of how the fire is developing. In this situation, says Davey, the hand-over occurred three times in five minutes and no-one got a full briefing period until things had settled down. Serious failures outlined As a consequence there were insufficient personnel available. Although a forward
command post was established on the 7th floor, two floors below where the fire started, it quickly spread to floors 3 and 11. With only 30 minutes of air in their breathing apparatuses, running between floors meant each person had only about seven minutes actual fire fighting time. All the while fire fighters were required to engage in search and rescue. “They were overwhelmed, under a lot of pressure and unable to formulate a proper plan which would normally have happened in a fairly structured way.” Davey was required to be in court for the 10-week inquest which concluded in February and then after returning home to his farm near Oamaru was back in London giving final evidence and being cross examined before a jury. The verdict was delivered in April. The jury highlighted numerous ways in which the three women and three young children from Brazil, Nigeria and Hampshire, could have been saved, saying the fire was ‘preventable’. The jury heard Southwark Council, responsible for fire safety checks at its flats since 2006, had not completed these on the Lakanal Block or other similar residential blocks by 2009, resulting in “a serious failure” by the council and its contractors. The court was told that a proper inspection would have picked up work that had been ongoing from the 1980s where vital fire-stopping material between flats and communal corridors was removed. The replacement of asbestos window panels with composite equivalents that burned in less than five minutes was also an issue. Deputy coroner Kirkham, recommended fire services visit high-rise blocks to learn their layout, landlords consider fitting sprinkler systems and residents also get better fire safety information. June - July 2013
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