Grenfell & the early departure of LFB Commissioner Dany Cotton: Some facts.

This blog provide some facts surrounding the early departure of Dany Cotton as the Commissioner of the London Fire Brigade (LFB). I’m in no way attempting to lay blame. I’m not offering a view about whether the decision was correct or not. I’m a fierce defender of the firefighters on the ground and I believe there are lessons to be learned.

I’m concerned that many of the current hero/villain narratives are inhibiting our ability to engage in the type of enquiry and debate that will lead to change. I’m hoping this context and background will enable more reflective and less reactionary debate.

My thoughts are with Ms Cotton, her family and colleagues. There is nothing easy about this.

I consider

I focus on the Grenfell Tower Phase 1 Report findings regarding Compliance with Building Regulations (Chapter 26) and the Planning and Preparation by the LFB (Chapter 27). Unless otherwise stated – all references (pp x; para x.x) refer to the Grenfell Tower Phase 1 Report.

The LFB Commissioner

Thanking Ms Cotton for her service, Mr Khan said: “I believe this decision is the right one.”

He added: “I will be appointing a new Fire Commissioner shortly and it’s right that they can quickly take on the responsibility to drive forward the changes being made within the Brigade, and to deliver on the recommendations made in the Grenfell Tower Inquiry report.”

Sadiq Khan London Mayor

On Friday 6th December we heard that that Dany Cotton, the Commissioner of the London Fire Brigade (LFB) would step down on the 31st December. Bringing forward her planned retirement.

  • Dany Cotton has held the post of Commissioner since 1 April 2017.
  • Prior to that (from 2015) she was Director of Safety and Assurance.
  • She is retiring on full pension and being paid in full through to her planned retirement date in April.

Her departure is reported to be a result of a meeting between the London Mayor (Sadiq Khan) and representatives of those affected by the fire.

The obligations of the Commissioner include: (Grenfell Tower Phase 1 Report, Volume 1: page 53, para 7.2, 7.3, 7.4)

  • The promotion of fire safety and making provision for the extinguishing of fires and protection of life and property
  • To fulfil this obligation requires the Commissioner
    • to secure the provision of the personnel, services and equipment necessary efficiently to meet all normal requirements
    • to secure the provision of training for personnel
    • to make arrangement for dealing with calls for help and for summoning personnel
    • to make arrangements for obtaining information needed for extinguishing fires and protecting life and property.
  • The Commissioner is appointed by and accountable to the Mayor of London.

Compliance with Building Regulations (Chapter 26)

With regards the building, the Phase 1 report concludes that the external facade was non-compliant with Building Regulations.

The functional requirement of B4(1) of Building Regulations requires the external walls of a building ‘to adequately resist the spread of fire over the walls… with regard to the height, use and position of the building’ (pg. 583, para 26.2)

Although not originally the intention to reach conclusions about the tower’s compliance to regulations in Phase 1. Moore-Bick said that

I accept that the construction of the Building Regulations is ultimately a question of law and there is compelling evidence that requirement B4(1) was not met in this case. It would be an affront to common sense to hold otherwise… In this case, whether one considers the rain screen panels alone or the cladding system as a whole, or even the complete external envelope, including the original concrete structure, it is clear that the walls did not resist the spread of fire. On the contrary, they promoted it, as can be seen in the video recordings of the rapidly developing fire which engulfed the building in just over 2.5 hours.’ (pg. 583, para 26.4)

He also says that prior to the refurbishment the exterior walls complied fully with this requirement. (pg. 583/584, para 26.5)

The question as to how those responsible for the design and construction of satisfied themselves that it did meet regulations is a matter for Phase 2. (pp. 584, para 26.7)

LFB Planning and Preparation (Chapter 27)

Risk Assessments (GRA 3.2 and LFB PN633)

Generic Risk Assessment 3.2 is a national guidance from which local fire and rescue services (such as the London Fire Brigade (LFB) derive their own policies. PN633 is the LFB’s policy for high rise buildings. (pp. 586, para 27.4)

The purpose of Generic Risk Assessment (GRA 3.2) was to assist fire and rescue services drawing up their own assessment of risk to meet their statutory obligations under the Health and Safety at Work Act. (pp. 585 pp. 27.1)

GRA 3.2 recommended (pp 585, para 27.1)

  • contingency plans for individual premises should be drawn up which. cover the spread of fire beyond the compartment of origin
  • the possible need for multiple rescues
  • the need for an operational evacuation plan in case ‘stay put’ became untenable.

The fire and rescue service were expected to provide those who became Incident Commanders with training in evacuation and casualty removal tactics, as well as training to enable them to recognise when a full or partial evacuation became necessary. (pp 585, para 27.1)

Extract from GRA 2 (pp. 585, para 27.2)

PN633 (the LFB high rise policy) based on the national guidance was neither as clear or extensive as GRA 3.2. In particular it did not spell out what LFB officers should do to prepare and initiate a contingency plan for evacuation. It did, however, envisage that evacuation of a high rise may be necessary. In particular

Extract from PN633 (pp. 586; para 27.5)

Moore-Bick identifies the following weaknesses with PN633. (pp 586, para 27.6)

  • it does not make clear to incident commanders that the existence of a stay put strategy should not defer them from undertaking a full or partial evacuation if the behaviour of the fire justifies it
  • it does not require any contingency for evacuation to be undertaken or give any guidance to incident commanders on how to go about carrying one out.

It does however proceed on an assumption that compartmentation may fail and that under those circumstances an incident commander must be prepared to carry out a full or partial evacuation.

Extract from PSN633, pp. 587, para 27.7

There were no tactical or contingency plans for the evacuation of Grenfell Tower.

The LFB’s knowledge of cladding fires

Moore-Bick concludes that the absence of an operational evacuation plan was a major omission in the LFB’s preparation but, since no attempt was made to carry one out, it was less significant than the absence of training on how to recognise the need for evacuation. He says that this reflects a failure to recognise the risk of fire taking hold on the outside of modern buildings. (pp. 587, para 27.9)

Several LFB witnesses said that the fire ‘should not behave like that’, which reflected a failure to educate firefighters of the dangers associated with combustible cladding systems. (pp. 587, para 27.9)

The failure to train firefighters in cladding fires is seen as surprising given the long history of such fires starting with Knowsley Heights in 1991 (pp. 587, para 27.10 – 12).

A presentation entitled ‘Tall Building Facades’ was apparently prepared by the LFB’s Fire Safety Regulation department in the latter quarter of 2016. The general conclusions of the slide presentation was…

Extract from ‘Tall Building Facades’ presentation, pp 588, para 27.12

Following a fire at Shepherd’s Bush Court in May 2017, AC Dan Daly, then Head of the LFB’s Fire Safety Regulation department wrote to the Chief Executives of all London Boroughs. Titled ‘Tall Buildings – External Fire Spread’ it made three points…

  1. As a result of recent incidents the LFB had found that the level of fire protection provided by the external surfaces did not comply with the requirement of building regulations in terms of limiting the speed at which a fire could spread…
  2. Testing of the external panels at the Shepherd’s Court fire had disclosed they did not meet the requirement of building regulations in terms of combustibility…, and
  3. Chief Executives should consider carefully their arrangements for specifying, monitoring and approving all aspects of future replacement and improvement to building facades and construction of new buildings

In relation to buildings within local authorities, the letter encouraged Chief Executives to think about including in their risk assessment process consideration of the extent to which external panels complied with building regulations. (pp 588, para 27.13)

Despite the history of cladding fires, the LFB’s experience at Shepherd’s Bush in August 2016 and the letter to the Chief Executives very few (if any) of the incident commanders at Grenfell Tower were aware of the risks posed by exterior cladding. (pp. 588, para 27.12)

The LFB Commissioner Dany Cotton, who was in charge of Safety and Assurance at the time of the production of the Tall Building Facades slide presentation, said she was unfamiliar with it at the time of the fire and could not explain why it’s circulation was limited to a small number of fire engineers. (pp. 588/589, para 27.14)


Despite the terms of GRA 3.2, the relevant paragraphs of PN633, the contents of the Tall Building Facades slide presentation and AC Daly’s letter the attitude to planning for the evacuation of a high-rise building was summed up by the Commissioner in her oral evidence. She said the LFB would not prepare a training package to respond to something that simply wouldn’t happen, or ‘for a space shuttle landing on the shard’. (pp. 589; para 27.17)

The following is an extract from the oral evidence given in 2018 to the Grenfell Inquiry related to the ‘Tall Building Facade’ slide presentation.

LFB Commissioner, Oral Evidence, Grenfell Inquiry

Moore-Bick says that the evidence given by Dany Cotton betrayed an unwillingness to confront the fact that by 2017, the LFB knew (even if she personally did not) (pp. 589, para 27.17)

  • that there was more than a negligible risk of a serious fire in a high rise building with a cladding system
  • That there was a reluctance to accept that there was a risk that a fire of this kind and scale might occur in any building that had been provided with exterior cladding

Moore-Bick concludes that ‘although the wholesale failure of every layer of fire safety in the building may not have been reasonably foreseeable by the LFB, the risk of rapidly developing facade fires in high-rise buildings and the consequent deluge of FSG calls were well known to the LFB in June 2017.

The question why that knowledge had not informed relevant policies (e.g. PN633), training and operational procedures and practice will be considered in Phase 2.

The Commissioner in her oral evidence said that even if the incident commander had known these risks it would not have made any difference as the fire was always incapable of being extinguished. Moore-Bick said that ‘I have no doubt that to have known what he was facing once the fire had broken out in Flat 16 would have assisted WM Michael Dowden (the first Incident Commander) and those who succeeded him in assessing the need to evacuate the building and formulating an appropriate strategy, even if its execution had presented serious challenges’. (pp 589, para 27.18)

Moore-Bick says that the failure to train firefighters in how best to fight fires was the inevitable consequence of the LFB’s institutional failure to inform firefighters about the risks they present.

  • None of the members. of the first four crews (with significant experience as firefighters) had received any training on the risks posed by cladding fires or the techniques to deploy in fighting them.
  • None had received any training in when to withdraw stay put advice
  • None had received any training in how best to evacuate residents
  • None had received training on the Tall Building Facades slide presentation.

The training provided to the first four crews (and in particular to WM Dowden the first incident commander) did not adequately prepare them for the nature, speed and ferocity of the fire they faced.

LFB Visits (Section 7(2)(d))

Moore-Bick finds that the failure to appreciate the nature of the risks posed by the cladding was due in part to the approach adopted by the LFB to discharge its obligation under section 7(2)(d) of the 2004 Act. (pp.590; para 27.21)

Section 7(2) required the LFB to make arrangement for obtaining information needed for the purpose of extinguishing fires and protecting life and property.

The LFB sought to discharge this by sending fire crews to inspect building. Appendix 1 to PN633 contained a list of things to be inspected.

It read… ‘During 7(2)(d) visits personnel should ensure they are familiar with the following and their impact on firefighting and search and rescue operations.’

It then lists 22 matters which reflected many identified in GRA 3.2. (Note: In this context ‘should’ means ‘must’ pp.590 para 27.22) This list included considering the likelihood of any fire spread beyond the compartment of origin and the potential for multiple rescues.

During her evidence the LFB Commissioner said that no training was given to fire-fighters in how to conduct the visits and expressed scepticism (as did other fire-fighter witnesses) about how realistic it was to expect frontline firefighters to undertake lengthly surveys. (pp. 591; para 27.24)

Although the requirement was to familiarise themselves with all the listed aspects, it is clear that as a matter of practice the LFB officers conducting visits did not consider all of them but concentrated on those relating to particular cause or event that prompted the visit. (pp. 591, para 27.25)

In the case of Grenfell, although the local fire station was aware of the refurbishment there was no attempt to carry out a visit which addressed each of the listed matters.

In this respect the LFB as an institution failed to implement the requirement of GRA 3.2 and PN633 by failing to train frontline officers on how to carry out proper section 7(2)(d) inspections. Phase 2 will examine whether these inspections should by conducted by suitably qualified professionals in addition to fire crews (pp. 592; para 27.27)

The LFB Commissioner Oral Evidence

The following is an extract from the LFB Commissioner’s oral evidence at the Grenfell Tower Inquiry.

Oral of evidence transcript. page 236.

Below are links to videos of the full evidence given by Dany Cotton during the Grenfell Tower Inquiry.

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  1. Thanks for this, very helpful and the link to your post on apportioning error correctly. As you say, we will only know the full truth once the 2nd report is out, the sooner the better I think given the repercussions of the first one.

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