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Lakanal: missed opportunities

The Lakanal House coroner’s inquest provided several opportunities to change the system before the tragedy at Grenfell Tower. Inside Housing’s news team looks at three areas where change came too late.  Photography by Getty/Rex Features/Press Association

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Lakanal: missed opportunities

It began with a faulty electronic appliance starting a fire in a flat. But the flames spread across the outside of the building, taking hold on cheap composite panels, not compliant with building regulations, which had been fitted during a refurbishment. Terrified residents called emergency services and were told to stay put in their homes, where they later died.

In the aftermath, questions were asked. How did risk assessments miss this? How did the system of building regulation allow the refurbishment to take place? How could this happen so close to the wealthiest part of one of the wealthiest cities on earth?

In social housing right now it seems history repeats itself twice as tragedy. Because this is not a description of the Grenfell Tower disaster, but Lakanal House – a fire eight years earlier and just a few miles away, south of the river.

The Lakanal disaster, which killed six including three young children, sparked a long coroner’s inquest which in turn sparked several recommendations about what should change in the social housing sector to prevent a recurrence.


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These warnings were not heeded. The national media was quick to pick up on the government’s failure to follow through with a core recommendation to review the ‘Approved Document B’ – the building guidance which the coroner described as “a most difficult document to use”. It is also commonly known, thanks to an Inside Housing investigation in 2015, that advice to consider the retro-fitting of sprinklers in high rises had no real impact.

But the learnings from Lakanal were many – and these are not the only ones with direct relevance to Grenfell which appears to have slipped through the net. Here we analyse three key areas: fire risk assessments, the stay put policy, and an attention to fire safety in building refurbishments, all of which were missed and all of which might have saved lives.

Fire risk assessments

Evidence at Lakanal showed a litany of problems with the interior of the building which allowed smoke and flames to spread. This had not been picked up through fire risk assessments.

As coroner Frances Kirkham said, “evidence was given that a fire risk assessor should inspect individual flats or maisonettes within a high-rise residential building to be able to inspect any features which could be seen inside but not outside… which might indicate the compartmentation had been breached”.

She therefore wrote to Eric Pickles, then-communities secretary, warning that there “remains uncertainty” over what fire risk assessments of tower blocks should include.

Ms Kirkham called on the government to provide clear guidance on how “common parts” of a tower block should be defined, how to inspect a flat to check if there is a compartmentation breach and how to inspect a sample of flats for compartmentation breaches.

Mr Pickles said he was confident guidance produced by the Local Government Association (LGA) in 2011 “addresses sufficiently those issues”, but that he would consider whether it needed to be revised in light of the coroner’s recommendations.

When Inside Housing asked what had been done since then to update the guidance, a spokesperson for the Department for Communities and Local Government (DCLG) directed us to an LGA update from May 2012 in which it said government and housing sector representatives were “satisfied” the guidance did not need updating.

But Inside Housing’s recent investigation looking at more than 400 fire risk assessments for tower blocks around the country suggests otherwise. Just one of these assessments was a ‘Type 4’, which looks at internal features. All of the rest with a rating were ‘Type 1’ assessments, which only look at the common areas of a building such as the lobbies, corridors and staircases.

Ronnie King, former fire fighter and honorary secretary of the All-Party Parliamentary Fire Safety & Rescue Group, says: “Unless assessors go into flats and the cavities and ducting then there’s no point. Fire resistance can get punctured by people breaking into cavities to do other work.”

Indeed, when Grenfell Tower was last risk assessed the review only covered the communal areas, the assessor has confirmed to Inside Housing. This meant it did not assess, for example, the cladding on the exterior of the 24-storey building.

‘Stay put’ policy

“Escape would have been daunting, but not impossible.” That was part of the Lakanal jury’s narrative verdict

following the death of Catherine Hickman, a 31-year-old woman who was consumed by smoke and heat after being told to stay in her flat by 999 operators. She had explained the layout of Lakanal House to the fire brigade control officers and described being affected by smoke and fire.

“There was a clear expectation by brigade control operators that persons trapped would be rescued by fire fighters,” the verdict says. “Their advice to the caller relied heavily on this assumption.”

The call handler’s training “failed to promote active listening” or “encourage operators to react to dynamic or unique situations”, the verdict claims. In short, Ms Hickman was let down by advice given over the phone in her final minutes.

The London Fire Brigade had already issued new guidance on fire survival calls to its control officers when the inquest findings were published. Following Ms Kirkham’s report, the brigade promised to carry out four annual training exercises for all its operational staff on the issue. Ms Kirkham also called on the DCLG to publish national guidance on stay put advice, which it did in February 2014.

The guidance warns that a stay put policy “may become untenable due to unexpected fire spread”, and says incident commanders “should understand” when evacuation becomes necessary. It also states: “Occupants (if they are able to) should self-evacuate when the fire, heat or smoke is adversely affecting them in their property.”

“One thing I am concerned about is that they need a plan B. I’m not sure they have a plan B.”

But, tragically, it appears that this guidance was not put into practice during the Grenfell Tower fire.

Eyewitnesses recall emergency services personnel calling up telling people in rooms to stay put as the flames took hold of the outside of the building. Multiple survivors have reported being told to stay in their flats by 999 operators, even after saying they could smell smoke – and this policy was not changed for nearly two hours, by which time the blaze had reached most of the building.

“The ‘stay put’ policy is almost applied like a mantra,” says Edwin Galea, director of the Fire Safety Engineering Group at the University of Greenwich. “One of the things that I am concerned about is that they need to have a plan B. I’m not sure they have a plan B.”

This need for a plan B was identified after Lakanal. It does not appear to have been applied at Grenfell Tower.

Refurbishment

The long chain of sub-contractors involved in the refurbishment of the tower has been scrutinised since the Grenfell fire.

The coroner’s recommendations after Lakanal reveal that the same issue dogged that inquest. The jury concluded flammable cladding panels were installed due to a “serious failure” by contractors and council staff procuring refurbishment work.

In her letter to Southwark Council, Ms Kirkham said: “It is recommended that your authority considers the training needs of staff involved in procuring or supervising work to existing high-rise residential buildings… to ensure that materials used… have appropriate fire protection qualities.”

But if this lesson was taken on board in one corner of south London, it appears to have been missed elsewhere.

Michael Carlish managed an estate regeneration project in Hammersmith and Fulham 10 years ago that saw flammable window panels fitted to high-rise blocks, He says: “It’s unusual [for councils to] have a competent fire risk assessor procuring the work and commenting on design schemes. You’ve got a gap in expertise about managing the risk of fire.”

At Grenfell, the addition of cladding was not considered serious enough to be included in subsequent fire risk assessments, nor was the temporary removal of fire stopping between floors. Indeed, papers from the council’s Housing Scrutiny Committee reveal no evidence that staff considered fire safety to be a relevant factor in awarding the Grenfell refurbishment contract at all. Staff were so unaware of the potential risks that a meeting of the tenant management organisation resolved to “extend [the] fire safety approach adopted at Grenfell Tower to all major works projects”.

Rudi Klein, chief executive of the Specialist Engineering Contractors’ Group, calls for “a revolution” in procurement. “There’s very little contact between those who do the final installation and those who do the original procuring,” he explains. “Those responsible for procuring the work on Grenfell Tower simply didn’t have access to the technical expertise in the supply chain.”

Perhaps, post-Grenfell, these lessons will be taken to heart. But the fact it took this long only increases the scope of the tragedy.

Reporting by Sophie Barnes, Nathaniel Barker, Luke Barratt and Pete Apps

Never Again campaign

Never Again campaign

Inside Housing has launched a campaign to improve fire safety following the Grenfell Tower fire

Never Again: campaign asks

Inside Housing is calling for immediate action to implement the learning from the Lakanal House fire, and a commitment to act – without delay – on learning from the Grenfell Tower tragedy as it becomes available.

LANDLORDS

  • Take immediate action to check cladding and external panels on tower blocks and take prompt, appropriate action to remedy any problems
  • Update risk assessments using an appropriate, qualified expert.
  • Commit to renewing assessments annually and after major repair or cladding work is carried out
  • Review and update evacuation policies and ‘stay put’ advice in light of risk assessments, and communicate clearly to residents

GOVERNMENT

  • Provide urgent advice on the installation and upkeep of external insulation
  • Update and clarify building regulations immediately – with a commitment to update if additional learning emerges at a later date from the Grenfell inquiry
  • Fund the retrofitting of sprinkler systems in all tower blocks across the UK (except where there are specific structural reasons not to do so)

We will submit evidence from our research to the Grenfell public inquiry.

The inquiry should look at why opportunities to implement learning that could have prevented the fire were missed, in order to ensure similar opportunities are acted on in the future.

 

READ MORE ABOUT THE CAMPAIGN HERE

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