Fire risk assessment failures
181 items
2 sources
Systemic failures in fire safety, including inadequate risk assessments and unaddressed actions, posing risks to residents.
Cross-Source Insight
Fire risk assessment failures has been flagged across 2 independent accountability sources:
113 inquiry recs
68 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (113)
FENN-1 — Install heat and smoke detectors on escalator trusses and machine rooms
Recommendation: All escalator trusses shall be fitted with linear heat detectors and machine rooms with smoke detectors. Priority should be given to escalators with wooden components and consideration given to moving the water fog valves to a protected location outside the …
Unknown
FENN-10 — Mark fire hydrants and cabinets with clear outrigger signs
Recommendation: Fire hydrants and cabinets must be marked with outrigger signs.
Unknown
FENN-120 — Resolve legal uncertainty regarding fire certification for underground stations.
Recommendation: The law on fire certification as it relates to underground stations is in a state of uncertainty. Steps should be taken to resolve the position.
Unknown
FENN-121 — Install comprehensive fire and smoke detection with automatic extinguishing in stations.
Recommendation: Comprehensive fire and smoke detection equipment, providing for remote monitoring and automatic operation of extinguishing devices, shall be fitted in underground stations as appropriate.
Unknown
FENN-122 — Initiate research into paint fire qualities for London Underground Code of Practice.
Recommendation: London Underground shall initiate a programme of research into the fire qualities of paint. The surface to which it is applied and the method of application must be considered. The result of this research must be incorporated in the Code …
Unknown
FENN-123 — Consult LFB and RI on fire safety for future station refurbishments.
Recommendation: London Undergound shall consult the London Fire Brigade and Railway Inspectorate about the means of escape and fire precaution measures in all future station refurbishment schemes.
Unknown
FENN-124 — Survey secondary escape routes from stations and assess conversion costs.
Recommendation: London Underground shall undertake a survey to identify secondary means of escape from stations and the costs of conversion.
Unknown
FENN-125 — Study optimal methods for controlling smoke and ventilation in stations.
Recommendation: London Underground must study the best way in which smoke and ventilation can be controlled.
Unknown
FENN-127 — Re-examine Code of Practice regarding fire-loadings in escalator shafts and stations.
Recommendation: London Underground shall re-examine its Code of Practice as it relates to the fire-loadings in escalator shafts and other regions of stations.
Unknown
FENN-135 — Review DoT Railway Construction and Operation Requirements for underground railways and stations.
Recommendation: The 'Department of Transport Railway Construction and Operation Requirements' in respect of underground railways and stations shall be reviewed, together with the letter dated 10 November 1958 to the railway undertakings entitled 'Submission of new works for approval by the …
Unknown
FENN-136 — Fire authority and RI to scrutinise new station designs for passenger safety.
Recommendation: The designs for new stations or significant alterations to stations shall be scrutinised by the fire authority and the Railway Inspectorate with special regard to passenger safety and fire precautions.
Unknown
FENN-15 — Modify London Underground fire equipment to London Fire Brigade standards
Recommendation: London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations agreed.
Unknown
FENN-155 — Review Fire Services Act to clarify police and fire brigade responsibilities
Recommendation: A review shall be undertaken of section 30 of the Fire Services Act 1947 to clarify the responsibilities of the police and the fire brigade.
Unknown
FENN-16 — Research air movement and provide criteria for safe train operation during fire
Recommendation: London Underground shall undertake further research into the effect of trains on air movement in the Underground. London Underground should provide criteria by which line controllers, who have received a report of fire, can judge whether it is safe to …
Unknown
FENN-19 — Ensure water gas fire extinguishers are safe near electrical equipment
Recommendation: Water gas fire extinguishers shall be made safe to use in the vicinity of electrical equipment.
Unknown
FENN-2 — Establish annual escalator replacement programme and review design for cleaning
Recommendation: A replacement programme of six or more escalator renewals per year shall be established. Escalator design shall be reviewed to allow easier and more effective cleaning.
Unknown
FENN-20 — Produce and maintain up-to-date station plans in LFB-agreed locations
Recommendation: In agreement with the London Fire Brigade, London Underground shall produce and maintain up-to-date station plans, and place them in boxes it has provided, at locations agreed or specified by the London Fire Brigade.
Unknown
FENN-21 — LFB to attend construction meetings, register risks, relocate affected equipment
Recommendation: The London Fire Brigade shall attend all pre-start meetings and important later meetings in relation to construction works on the Underground. Details of the works shall be included on the Fire Brigade's central risks register. Fire equipment and London Fire …
Unknown
FENN-27 — Review LFB policy and training for alternative underground fire access
Recommendation: The London Fire Brigade shall review its policy and training on the use of alternative means of access to an underground fire.
Unknown
FENN-29 — Ensure LFB officers are familiar with underground station geography and layout
Recommendation: The London Fire Brigade shall ensure that its officers are made familiar with the geography and layout of underground stations on their own and adacent fireground lerritories.
Unknown
FENN-35 — Replace wooden escalator skirting, balustrade, decking, and panels with metal
Recommendation: The wooden skirting boards and balustrade, decking and advertisement panels of all escalators must be replaced with metal by July 1989.
Unknown
FENN-36 — Urgently replace wooden escalator risers due to 'trench effect' discovery
Recommendation: Replacement of the wooden risers must be urgently sought in view of the discovery of the 'trench effect' and the conclusions of the report referred to in Appendix G as Report 4n.
Unknown
FENN-37 — Complete initial manual cleaning programme for escalator tracks and panels
Recommendation: The initial programme for manual cleaning of tracks and step chains together with the spaces behind balustrade and decking panels must be completed.
Unknown
FENN-38 — Determine escalator cleaning frequency from surveys of grease and fluff buildup
Recommendation: The frequency of escalator cleaning must be determined from surveys of the rate at which grease and fluff builds up at different sites.
Unknown
FENN-39 — Implement regular escalator cleaning, improving access and protective clothing for staff
Recommendation: Escalators shall be manually cleaned at least every six months until the rewiring of machine rooms is completed. Thereafter they shall be mechanically cleaned in accordance with the programme determined under Recommendation 38. Escalator steps must be removed as necessary, …
Unknown
FENN-4 — Fit sprinkler water supply with pressure gauge and by-pass valve
Recommendation: The water supply to sprinkler equipment shall be fitted with a pressure gauge and by-pass valve. London Fire Brigade should be invited to attend London Underground water fog tests.
Unknown
FENN-40 — Require station supervisors to inspect escalators and machine rooms every two hours
Recommendation: Station supervisors must personally inspect escalators, and both upper and lower machine rooms, every two hours until wooden parts have been removed.
Unknown
FENN-41 — Cease oil and spirit treatment of timber risers; replace missing fire cleats
Recommendation: The treatment of timber risers and step boards with oil and spirit must cease. Missing fire cleats must be replaced.
Unknown
FENN-42 — Research escalator shaft fire dynamics using models and computer simulation
Recommendation: Further research shall be undertaken into the dynamics of fires in escalator shafts by London Underground using the available scale models and computer simulation.
Unknown
FENN-45 — Regularly examine fire equipment, report defects, and ensure immediate remedy
Recommendation: London Underground shall regularly examine fire equipment and ensure that defects are reported and remedied at once or alternative arrangements made.
Unknown
FENN-46 — Continue annual LFB inspections, remedy defects, and publish reports publicly
Recommendation: The annual inspection by the London Fire Brigade of underground stations and tunnels shall continue, and unsatisfactory features must be remedied and reported on within six weeks. Copies of the reports shall be sent to the Chief Safety Inspector and …
Unknown
FENN-48 — Fit locked emergency gates with alarmed panic bars
Recommendation: Locked emergency gates shall be fitted with alarmed panic bars.
Unknown
FENN-49 — Check station ventilation and issue fire action instructions for contaminated air
Recommendation: Station ventilation systems must be checked to ensure that contaminated air cannot be introduced into the rooms they serve. Instructions must be issued on any action to be taken in the event of a fire.
Unknown
FENN-51 — Inspect and rectify electrical wiring in escalator machine rooms and shafts
Recommendation: Electrical wiring in escalator machine rooms and shafts shall be inspected and defects rectified.
Unknown
FENN-52 — Survey VIR cables, improve machine rooms, and waterproof electrical equipment for cleaning
Recommendation: A survey must be carried out of all remaining VIR cable installations and a renewal programme established. The electrical wiring, lighting, decoration, and general state of machine rooms and shafts must be improved. The waterproofing of electrical equipment to permit …
Unknown
FENN-53 — Implement regular cleaning of machine rooms and shafts with safe material storage
Recommendation: All machine rooms and shafts must be specially cleaned by the end of I988 and regularly cleaned thereafter. Essential cleaning materials shall be kept only in small quantities and in correctly marked containers in fire-proof bins.
Unknown
FENN-55 — Review fire section scope, effectiveness, and station fire equipment organisation
Recommendation: The Senior Fire Officer of London Underground, under the direction of the new Chief Safety Inspector, shall review the scope, effectiveness and organisation of the fire section and station fire equipment in consultation with the London Fire Brigade.
Unknown
FENN-6 — Seek and use non-inflammable escalator lubricant; improve lubrication methods
Recommendation: A non-inflammable escalator lubricant must be sought and used. Methods of lubrication must be improved.
Unknown
FENN-66 — Ensure daily rubbish removal from machine rooms and fire-protected bin rooms
Recommendation: Rubbish must be removed at least daily from machine rooms. Bin rooms must be located at ground level or protected against fire and frequently cleared.
Unknown
FENN-67 — Review Code of Practice administration and ensure material compliance for all works
Recommendation: London Underground shall review the administration of the Code of Practice for the use of materials. All materials used in new works, modernisation, or maintenance must comply with the Code of Practice unless a specific waiver is obtained.
Unknown
FENN-68 — Extend material use restrictions to all engineering departments and contractors
Recommendation: The restriction on the use of materials shall be extended to other engineering departments and must be applied to the work of contractors.
Unknown
FENN-69 — Survey system materials, evaluate risks, and remove hazardous materials programme
Recommendation: London Underground shall survey materials present on the system, evaluate the risks involved from those materials and devise a programme to remove those which constitute a hazard.
Unknown
FENN-7 — Modify remote monitoring equipment to record smoke and heat detector activation
Recommendation: The remote monitoring equipment being fitted to escalators and lifts shall be modified so as to record any activation of smoke or heat detectors. This work should be completed by the end of 1989.
Unknown
FENN-74 — Prohibit unprotected storage of combustible items at all Underground stations
Recommendation: Combustible items such as paper and card shall not be stored at stations unless properly protected from the risk of fire. This recommendation and the Code of Practice shall apply to all occupiers of premises on the Underground.
Unknown
FENN-76 — Empty escalator dust trays daily and examine design for damp contents
Recommendation: Escalator dust trays must be emptied daily and the design examined to see if the contents can be kept damp.
Unknown
FENN-81 — Establish continuing fire and safety instruction for station staff by supervisors
Recommendation: London Underground shall establish a programme of continuing instruction at work by supervisors for station staff in fire and safety with the assistance of the London Fire Brigade and British Transport Police. At stations equipped with water fog equipment supervisors …
Unknown
FENN-83 — Provide biannual fire and safety training for non-supervisory and shop staff
Recommendation: Every six months fire and safety training must be provided for non-supervisory staff and booking clerks. Staff must be given site familiarisation training before they are permitted to take part in the running of the station. Specific provision shall be …
Unknown
FENN-85 — Provide fire safety training for cleaning and engineering staff on stations
Recommendation: Fire safety training for cleaning and engineering staff working on stations shall be provided. London Underground must obtain expert advice.
Unknown
FENN-86 — Review station staff fire and safety training based on consultant advice
Recommendation: Fire and safety training for station staff shall be reviewed in the light of the advice from consultants.
Unknown
P1-1 — Require external wall information for fire services
Recommendation: The owner and manager of every high-rise residential building be required by law to provide their local fire and rescue service with information about the design of its external walls together with details of the materials of which they are …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-2 — Train fire personnel on external wall fire risks
Recommendation: All fire and rescue services ensure that their personnel at all levels understand the risk of fire taking hold in the external walls of high-rise buildings and know how to recognise it when it occurs.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-3 — LFB to review PN633 Appendix 1
Recommendation: The LFB review, and revise as appropriate, Appendix 1 to PN633 to ensure that it fully reflects the principles in GRA 3.2.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-30 — Require evacuation plans for high-rise buildings
Recommendation: The owner and manager of every high-rise residential building be required by law to draw up and keep under regular review evacuation plans, copies of which are to be provided in electronic and paper form to their local fire and …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
Delivered
P1-37 — Urgent fire door inspections required
Recommendation: The owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) carry out an urgent inspection of all fire doors to ensure that they comply with applicable legislative standards.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-38 — Require quarterly fire door checks
Recommendation: The owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) be required by law to carry out checks at not less than three-monthly intervals to ensure that all fire doors are fitted …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
Delivered
P1-39 — Require compliant flat entrance doors where unsafe cladding exists
Recommendation: All those who have responsibility in whatever capacity for the condition of the entrance doors to individual flats in high-rise residential buildings, whose external walls incorporate unsafe cladding, be required by law to ensure that such doors comply with current …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted in Part
Delivered
P1-4 — Train LFB officers on high-rise inspections
Recommendation: The LFB ensure that all officers of the rank of Crew Manager and above are trained in carrying out the requirements of PN633 relating to the inspection of high-rise buildings.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
Delivered
P1-5 — Require building floor plans for fire services
Recommendation: The owner and manager of every high-rise residential building be required by law to provide their local fire and rescue services with up-to-date plans in both paper and electronic form of every floor of the building identifying the location of …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-6 — Require premises information boxes
Recommendation: The owner and manager of every high-rise residential building be required by law to ensure that the building contains a premises information box, the contents of which must include a copy of the up-to-date floor plans and information about the …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-8 — Require monthly firefighter lift inspections
Recommendation: The owner and manager of every high-rise residential building be required by law to carry out regular inspections of any lifts that are designed to be used by firefighters in an emergency and to report the results of such inspections …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P1-9 — Require monthly lift control mechanism tests
Recommendation: The owner and manager of every high-rise residential building be required by law to carry out regular tests of the mechanism which allows firefighters to take control of the lifts and to inform their local fire and rescue service at …
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
Delivered
P2-10 — Require fire safety strategy from registered fire engineer at Gateway 2
Recommendation: That it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any higher-risk building and for it …
Gov response: The government accepts this recommendation. A fire safety strategy is already required with building control applications for the construction of and significant work to higher-risk buildings. The Building Safety Regulator will consider how to make …
Accepted
In progress
P2-12 — Clarify BS 9414 limitations requiring fire engineer assessment
Recommendation: BS 9414 should be approached with caution and we recommend that the government make it clear that it should not be used as a substitute for an assessment by a suitably qualified fire engineer. (113.18)
Gov response: The government accepts this recommendation. We will address this through the response to recommendation 5.
Accepted
In progress
P2-2 — Review Building Safety Act higher-risk building definition
Recommendation: That the definition of a higher-risk building for the purposes of the Building Safety Act be reviewed urgently. (113.7)
Gov response: The government accepts this recommendation. The Building Safety Regulator has conducted an initial review of the definition of a higher-risk building. Plans for an ongoing review, which will help strengthen the building system, reassure residents …
Accepted
Delivered
P2-20 — Require principal designer compliance statement at Gateway 2
Recommendation: That it be made a statutory requirement that an application for building control approval in relation to the construction or refurbishment of a higher-risk building (Gateway 2) be supported by a statement from a senior manager of the principal designer …
Gov response: The government accepts this recommendation. We intend to make it a statutory requirement to include such a statement with building control approval applications requiring the principal designer to confirm they have complied with their existing …
Accepted
In progress
P2-21 — Introduce licensing scheme for principal contractors
Recommendation: That a licensing scheme operated by the construction regulator be introduced for principal contractors wishing to undertake the construction or refurbishment of higher-risk buildings and that it be a legal requirement that any application for building control approval for the …
Gov response: The government accepts this recommendation. We will review the impact of the new dutyholder regime in relation to higher-risk buildings, working with the sector to determine how we can go further, including introducing a licensing …
Accepted
In progress
P2-22 — Independent panel review of building control commercial interests
Recommendation: That the government appoint an independent panel to consider whether it is in the public interest for building control functions to be performed by those who have a commercial interest in the process. (113.37)
Gov response: The government accepts this recommendation. An independent panel will be established to review the building control sector and will recommend which bodies should carry out certain functions, as well as whether all building control functions …
Accepted
In progress
P2-23 — Consider national building control authority
Recommendation: We recommend that the same panel consider whether all building control functions should be performed by a national authority. (113.38)
Gov response: The government accepts this recommendation. See recommendation 22.
Accepted
In progress
P2-24 — Create cladding materials library for designers
Recommendation: We have referred to the Cladding Materials Library set up by the University of Queensland, which could form the basis of a valuable source of information for designers of buildings in general. We recommend that the construction regulator sponsor the …
Gov response: The government accepts this recommendation. We accept the premise of better access to information, resources and test results through a digitally based library. In line with this we are considering options to best support access …
Accepted
In progress
P2-26 — Establish mandatory fire risk assessor accreditation
Recommendation: That the government establish a system of mandatory accreditation to certify the competence of fire risk assessors by setting standards for qualification and continuing professional development and such other measures as may be considered necessary or desirable. We think it …
Gov response: The government accepts this recommendation. We will legislate to make it a mandatory requirement for fire risk assessors to have the competence to perform this critical role independently verified by a UKAS-accredited Certification Body.
Accepted
In progress
P2-27 — Standardise fire control switches and keys
Recommendation: We are not in a position to determine whether greater standardisation of the fire control switches and keys is required. We therefore recommend that the government seeks urgent advice from the Building Safety Regulator and the National Fire Chiefs Council …
Gov response: The government accepts this recommendation. The National Fire Chiefs Council are reviewing the guidance for the provision of lift fire control switches with the Building Safety Regulator to support a view on standardisation in buildings. …
Accepted
In progress
P2-28 — Require gas valve accessibility inspections every three years
Recommendation: That every gas transporter be required by law to check the accessibility of each [pipeline isolation] valve on its system at least once every three years and to report the results of that inspection to the Health and Safety Executive …
Gov response: The government accepts this recommendation in principle. We agree with the Inquiry's findings that accessibility and functionality of such valves is key to ensuring health and safety by stopping gas supplies in an emergency. Whilst …
Accepted in Part
In progress
P2-29 — Establish independent College of Fire and Rescue
Recommendation: That the government establish [an independent College of Fire and Rescue] immediately with sufficient resources to provide the following services nationally: a) practical training at all levels supplementary to that provided by individual fire and rescue services; b) education in …
Gov response: The government accepts this recommendation in principle. We recognise the importance of making sure that fire and rescue services are appropriately trained and that high standards are maintained. The creation of a college was also …
Accepted in Part
In progress
P2-3 — Consolidate fire safety functions under single department
Recommendation: That the government bring responsibility for the functions relating to fire safety currently exercised by MHCLG, the Home Office and the Department for Business and Trade into one department under a single Secretary of State. (113.8)
Gov response: The government accepts this recommendation. Fire safety related functions will move from the Home Office to MHCLG. The National Regulator for Construction Products in the Department for Business and Trade already reports to MHCLG's Secretary …
Accepted
Delivered
P2-30 — College to have permanent staff and training facilities
Recommendation: That [the college] should have a permanent staff of sufficient size to manage its operations and develop its functions in response to the demands of fire and rescue services nationally and the requirements of the board. The college will need …
Gov response: The government accepts this recommendation in principle. See recommendation 29. This will be captured by the consultation on the most appropriate functions for the college to fulfil and how it could best be structured and …
Accepted in Part
In progress
P2-31 — Inspect London Fire Brigade control room operations
Recommendation: That His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (the Inspectorate) inspect the London Fire Brigade as soon as reasonably possible to assess and report on: a) the extent to which the control room is now integrated into …
Gov response: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) accepts this recommendation. HMICFRS most recently inspected London Fire Brigade in February 2024 on their effectiveness, efficiency and people management. The findings were published …
Accepted
Delivered
P2-32 — Inspect London Fire Brigade incident commander training
Recommendation: That as soon as reasonably possible the Inspectorate inspect the London Fire Brigade to examine and report on the arrangements it has in place for assessing the training of incident commanders at all levels and their continuing competence, whether by …
Gov response: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) accepts this recommendation. See recommendation 31.
Accepted
Delivered
P2-33 — Inspect London Fire Brigade information management systems
Recommendation: That as soon as reasonably practicable the Inspectorate inspect the LFB to examine and report on its arrangements for collecting, storing and distributing information in accordance with section 7(2)(d) of the Fire and Rescue Services Act 2004, and in particular …
Gov response: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) accepts this recommendation. See recommendation 31.
Accepted
Delivered
P2-34 — London Fire Brigade to establish lessons learned process
Recommendation: That the London Fire Brigade establish effective standing arrangements for collecting, considering and effectively implementing lessons learned from previous incidents, inquests and investigations. Those arrangements should be as simple as possible, flexible and of a kind that will ensure that …
Gov response: London Fire Brigade accepts all the recommendations relevant to them, including this one aimed directly at them. London Fire Brigade is committed to ensuring lessons from incidents are learned from and good practice is shared …
Accepted
In progress
P2-35 — Consider higher power radios for breathing apparatus
Recommendation: That fire and rescue services that continue to use low power intrinsically safe radios as part of breathing apparatus consider reserving them only for situations in which there is a real risk of igniting flammable gases and generally using radios …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC is surveying fire and rescue services to understand what arrangements are currently in place at a local …
Accepted
In progress
P2-36 — Provide firefighters with digital radios
Recommendation: That all fire and rescue services give consideration to providing all firefighters with digital radios. (113.60)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. See recommendation 35.
Accepted
In progress
P2-37 — Train firefighters on communications loss response
Recommendation: Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them. (113.61)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the content of national operational guidance and is surveying fire and rescue services to establish …
Accepted
In progress
P2-38 — Provide water supply system training to all firefighters
Recommendation: That basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training should also be given on effective measures to increase water …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the national operational guidance and is surveying fire and rescue services to establish what additional …
Accepted
In progress
P2-39 — Establish water undertaker communication protocols
Recommendation: That all fire and rescue services establish and periodically review an agreed protocol with the statutory water undertakers in their areas to enable effective communication between them in relation to the supply of water for firefighting purposes. (113.63)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC and fire service lead officers for water are discussing with water undertakers how to strengthen existing arrangements …
Accepted
Delivered
P2-40 — Amend BS 750 for flow coefficient measurement
Recommendation: That the British Standards Institution amend BS 750 to include a description of the circumstances under which the flow coefficient to which it refers in paragraph 10.2 is to be measured. (113.64)
Gov response: The British Standards Institution (BSI) accepts this recommendation. It will amend BS 750 accordingly and expect to publish the revised standard, following the usual standards development process and a period of public consultation, towards the …
Accepted
In progress
P2-41 — Consider guidance on firefighter initiative deviations
Recommendation: That National Fire Chiefs Council consider whether, and if so in what circumstances, firefighters should be discouraged from departing from their instructions on their own initiative and provide appropriate training in how to respond to a situation of that kind. …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation. Firefighters operate in an extremely high-risk and dynamic environment where responding to changes is essential to safe working practice. The ability to communicate changes in the …
Accepted
In progress
P2-5 — Review statutory guidance and Approved Document B
Recommendation: That the statutory guidance generally, and Approved Document B in particular, be reviewed accordingly and a revised version published as soon as possible. (113.11)
Gov response: The government accepts this recommendation. The Building Safety Regulator is undertaking a review of how statutory guidance, currently offered in the form of Approved Documents, might best be structured, updated and presented in order to …
Accepted
In progress
P2-57 — Reconsider Phase 1 recommendations in light of Phase 2
Recommendation: That further consideration be given to the recommendations made in the Phase 1 report in the light of our findings in this report. (113.82)
Gov response: The government accepts this recommendation. We addressed these recommendations in the response to the Emergency Evacuation Information Sharing Plus (EEIS+) consultation published on 2 December 2024.
Accepted
In progress
P2-58 — Reconsider LGA Guide paragraph 79.11 advice
Recommendation: That the advice contained in paragraph 79.11 of the LGA Guide be reconsidered. (113.83)
Gov response: The government accepts this recommendation. The advice contained in paragraph 79.11 of the LGA Guide was redacted in 2021. The Home Office intends to publish new guidance on the issues covered in paragraph 79.11 in …
Accepted
Delivered
P2-6 — Add legal requirements warning to statutory guidance
Recommendation: That a revised version of the guidance contain a clear warning in each section that the legal requirements are contained in the Building Regulations and that compliance with the guidance will not necessarily result in compliance with them. (113.12)
Gov response: The government accepts this recommendation. We will address this through the response to recommendation 5.
Accepted
In progress
P2-7 — Reconsider compartmentation in Approved Document B
Recommendation: New materials and methods of construction and the practice of overcladding existing buildings make the existence of effective compartmentation a questionable assumption and we recommend that it be reconsidered when Approved Document B is revised. (113.13)
Gov response: The government accepts this recommendation. We will address this through the response to recommendation 5.
Accepted
In progress
P2-8 — Require fire engineer calculations for fire spread and evacuation
Recommendation: Calculating the likely rate of fire spread and the time required for evacuation, including the evacuation of those with physical or mental impairments, are matters for a qualified fire engineer. We do not think that it would be helpful to …
Gov response: The government accepts this recommendation. We will address this recommendation through the ongoing Approved Document B review, led by the Building Safety Regulator. The review and industry engagement will explore ways through which Approved Document …
Accepted
In progress
P2-9 — Include academics on statutory guidance advisory bodies
Recommendation: That, as far as possible, membership of bodies advising on changes to the statutory guidance should include representatives of the academic community as well as those with practical experience of the industry (including fire engineers) chosen for their experience and …
Gov response: The government accepts this recommendation. We agree that a diverse range of representatives, including those from academic and professional communities, should be included in membership of bodies advising on changes to statutory guidance. The Building …
Accepted
In progress
POPP-A.10 — Train stewards in fire safety, firefighting, and assisting police with evacuation.
Recommendation: Stewards in all grounds should not only be trained in fire precautions and fire fighting (see Recommendation 7 above) but should also be trained in how best to help the police in evacuation.
Unknown
POPP-A.12 — Amend Green Guide for comprehensive steward training and instruction on emergencies.
Recommendation: The Green Guide should be amended to contain a specific provision, in relation to stewards, (i) that they should be trained and instructed to deal with any emergency relating to fire or evacuation (see also Recommendations 7 and 10); (ii) …
Unknown
POPP-A.13 — Prohibit construction of new permanent stands using combustible materials.
Recommendation: Building of new permanent stands of combustible materials should be prohibited as a general rule.
Unknown
POPP-A.15 — Prohibit smoking in combustible stands, enforce with entry conditions and signs.
Recommendation: No smoking should take place in combustible stands, that this should be a condition of entry to the ground and that signs to this effect should be prominently displayed.
Unknown
POPP-A.16 — Fire authorities must inspect stadia and restrict stands with inadequate fire precautions.
Recommendation: Fire authorities should identify and visit all sports stadia in their areas and should prohibit or restrict the use of any stands which, in their view, constitute a risk to spectators because of the inadequacy of the fire precautions.
Unknown
POPP-A.6 — Require suitable firefighting equipment in sports grounds without safety certificates
Recommendation: Those managing sports grounds not governed by safety certificates should give serious consideration, with the assistance of fire authorities, to the presence in a ground of suitable fire fighting equipment.
Unknown
POPP-A.7 — Require fire fighting training for all sports ground stewards
Recommendation: Stewards at all sports grounds should be trained in fire fighting.
Unknown
POPP-C.10 — Urgently amend Building Regulations for structural fire precautions in new stands
Recommendation: The Department of the Environment should urgently amend the Building Regulations Guidance Codes in relation to structural fire precautions in new stands.
Unknown
POPP-C.3 — Require fire certificates for sports grounds with stand capacity over 500
Recommendation: All sports grounds and sports stadia not already designated under the Safety of Sports Grounds Act 1975 and having a capacity in a stand of over 500 spectators should be designated under the Fire Precautions Act 1971 as premises requiring …
Unknown
POPP-C.5 — Mandate fire certificates for indoor sports facilities over 500 capacity
Recommendation: In England and Wales indoor sports facilities with accommodation for over 500 spectators should require a fire certificate under the Fire Precautions Act 1971.
Unknown
POPP-C.6 — Review and designate Scottish indoor sports facilities under 1971 Fire Act
Recommendation: An urgent review of the existing legislation on indoor sports facilities in Scotland should be undertaken and if they are not currently covered by fire regulations such facilities should be designated under the Fire Precautions Act 1971.
Unknown
POPP-C.7 — Grant fire authority officers power to issue fire safety prohibition notices
Recommendation: Provision should be made in the Fire Precautions Act 1971 for authorised officers of a fire authority to have power to issue a prohibition notice.
Unknown
POPP-C.8 — Grant local authority officers power to issue sports ground prohibition notices
Recommendation: Provision should be made for authorised officers of the local authority to have power to issue a prohibition notice under the Safety of Sports Grounds Act 1975.
Unknown
POPP-C.9 — Mandate annual renewal, inspection, and revocation of sports ground safety certificates
Recommendation: There should be (1) annual renewal of safety certificates issued under the Safety of Sports Grounds Act 1975; (2) a duty on the local authority annually to inspect the premises prior to re-issuing the certificate and (3) power for the …
Unknown
RONA-20 — Extend London Gas Act nationwide, mandate free inspection, refuse unsafe gas
Recommendation: The London Gas Undertakings (Regulations) Act 1939, should be given statutory authority, and extended to cover the whole country, and this obligation should be coupled with the duty of the area Gas Board to inspect, and to refuse supply of …
Unknown
RONA-21 — Investigate and implement improved ventilation in high-rise flats
Recommendation: Consideration should be given to means of improving ventilation in flats in high blocks {paragraph 172}.
Unknown
RONA-22 — Review regulations for storing explosive materials in high-rise residential blocks
Recommendation: The Regulations governing the storage of other potentially explosive materials in high blocks of flats should be reviewed {paragraph 173}.
Unknown
RONA-31 — Strengthen blocks inadequately designed to resist wind loads or fire
Recommendation: Where blocks are inadequately designed to deal with wind loads, or fire, they should be adequately strengthened {paragraphs 214 and 216}.
Unknown
RONA-34 — Designers to ensure tall blocks are fire protected until new Code
Recommendation: Until such time as a new Code of Practice has been prepared, designers of tall blocks should ensure that the structure is adequately protected from the effects of fire {paragraph 216}.
Unknown
RONA-46 — Revise Fire Regulations for high-rise structural behaviour during normal intensity fires
Recommendation: The Fire Regulations should be revised to take account of the behaviour of the structure of high rise buildings in the event of fire of normal intensity {paragraph 216}.
Unknown
PFD Reports (68)
Jacqueline Joseph
Concerns: The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
Pending
Ricky Monahan
Concerns: An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines for fire escape protections in such settings.
Response: NHS England states that appropriate national guidance regarding patient safety and risk assessment in mental health settings already exists, implying the issue was with local implementation of environmental risk assessments …
Response: The Environmental Risk Assessment has been updated to include the fire escape, and the Trust has installed new metal fence panels and an eight-foot-high gate on the ground floor and …
Response: The CQC outlines its existing regulatory duties under Regulation 12 regarding safe care and treatment, and explains its inspection processes, but states the issue of national guidelines for fire escape …
Responded
James Rownsley
Concerns: There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related deaths also show significant discrepancies.
Responded
Thomas Hill
Concerns: A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of an external warning label obscured safe usage requirements from users.
Responded
Ruth Pingree
Concerns: Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Responded
Gary James
Concerns: The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety concerns and supervision.
Responded
Liam Allan
Concerns: Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Responded
Muhammad & Naemat Esmael
Concerns: Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to activate in a contained bedroom fire, posing a risk to life. Crucial items were also prematurely removed from the fire scene, hindering investigation into the cause.
Responded
Wessam al Jundi
Concerns: Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current surveillance is insufficient for this accelerated disease, risking future deaths.
Responded
Margaret Aitchison
Concerns: A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.
Responded
Raymond Brattley
Concerns: There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such as using metal bins and fire-retardant materials.
Responded
Saffra Winn
Concerns: Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures for investigating and assessing risks following catastrophic incidents in social housing.
Responded
REDACTED
Concerns: There were concerning delays in the London Fire Brigade's response, specifically in deploying an extended height ladder appliance, to a person on a block of flats roof.
Responded
Frederick Powell
Concerns: Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even if current building regulations are met.
Responded
Mackenzie Cooper
Concerns: A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for defibrillator status is also lacking.
Responded
Tomas Ceida
Concerns: Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding building safety. There is also a lack of clarity on fire safety responsibilities for contractors.
Overdue
Stephen Preston
Concerns: Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and safety regulations, and their proximity to stairs poses a significant risk.
Overdue
Keith Holmes
Concerns: Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for future lockdown scenarios.
Responded
Ashleigh Timms
Concerns: Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.
Responded
Sean Ennis
Concerns: Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions and monitoring, exacerbated by a lack of person-centred risk assessments and accreditation.
Responded
Christian Hinkley
Concerns: Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. Despite repeated warnings and notices issued since 2015, in-cell automatic fire detectors remain uninstalled.
Overdue
Barry Martin
Concerns: Following forced police entry, an occupied house was left with its main exit boarded up and the secondary exit unusable, creating a significant fire safety risk by denying residents alternative escape routes.
Responded
James Golds
Concerns: Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler requirement and ineffective smoke detector placement.
Responded
Henry Boddy
Concerns: There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire loads arising from hoarding behavior.
Responded
Netlyn Robinson
Concerns: Critical failures in discharging a vulnerable person home included no falls alarm, no working phone, no risk assessment for emergency contact, unchecked utilities, and inadequate social worker training on home suitability checks.
Responded
Darrell Spear
Concerns: Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication and a lack of clear strategy.
Overdue
Jaden Francois-Espirit
Concerns: The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.
Responded
John Jennings
Concerns: Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, which may compromise safety.
Responded
Pauline Oakley
Concerns: There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.
Responded
Peter Moran
Concerns: Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.
Responded
Kenneth Bardsley
Concerns: Lack of minimum qualifications for lift engineers, a systemic failure to act on regulatory examination findings, and absent care home and lift company protocols for managing maintenance risks contributed to safety concerns.
Overdue
Mihaela Lazar
Concerns: Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes in older maisonettes, pose a significant fire risk in thousands of properties.
Overdue
Barnaby Aylward
Concerns: Systemic failure in multi-agency review and responsibility for known home safety risks linked to mental illness was compounded by poor communication and inadequate mental health documentation. Family support was also insufficient.
Overdue
Brian Frost
Concerns: Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Overdue
Canon Frost
Concerns: Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Responded
Matthew Hatfield
Concerns: Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a design flaw allowing guns to fire without a vital safety assembly.
Responded
Elizabeth Griffin
Concerns: No specific concerns for future deaths were detailed in the provided text.
Overdue
Christopher Brookes
Concerns: Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols and response.
Overdue
John Nichols
Concerns: The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.
Responded
Bernard Hender
Concerns: Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.
Responded
Brian MaClean
Concerns: Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install automatic water suppression systems and appropriate alarms for high-risk individuals.
Overdue
Ian Leak
Concerns: The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious safety concerns for residents, particularly those with mobility problems under a "Stay Put" policy.
Overdue
Sheila Gaskin
Concerns: Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear prohibition policy.
Responded
Pauline Taylor
Concerns: Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Overdue
John Wilson
Concerns: The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts like registered post or follow-up visits, despite known increasing fire risk with product age.
Overdue
Patrick Woods
Concerns: The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.
Responded
Rasikaben Chauhan
Concerns: There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.
Responded
Russell Sherwood
Concerns: The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.
Responded
Sharon Soares
Concerns: There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.
Overdue
Cedric Skyers
Concerns: The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not document refusal of professional advice.
Responded
Ellen Kelly
Concerns: Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread and trapping residents.
Responded
Christine Dryden
Concerns: The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating a review of maintenance arrangements.
Overdue
Andrew Coates
Concerns: An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific site, exacerbated by sketchy inspection records.
Responded
George Hines
Concerns: Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control room, delaying fire alerts.
Overdue
Emma Waring
Concerns: The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.
Responded
Christianne Shepherd
Concerns: Systemic failures include a lack of central register for hotel safety data, poor tour operator collaboration, insufficient carbon monoxide awareness, and delegation of critical health and safety checks to inexperienced staff.
Pending
Ian Morley
Concerns: A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Overdue
Kenneth Bailey
Concerns: Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing their risk of injury or death.
Responded
Robert Spring
Concerns: Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.
Responded
Anne Fowler
Concerns: Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.
Overdue
Christopher Butler
Concerns: A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that standard electrical testing may miss. The Fire and Rescue Service needs to alert the community.
Responded
Richard Turner
Concerns: Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of lifting plans, risks, and infrequent safety briefings.
Overdue
Santosh Muthiah
Concerns: The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes product safety investigations.
Responded
Robert Wood
Concerns: Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw appliances.
Pending
Magdalen Dwerryhouse
Concerns: Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.
Responded
Walter Gordon Powley
Concerns: Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Response: The CQC acknowledges its inspector did not assess against relevant regulations for premises safety in this case. They are piloting a new inspection methodology that will focus on safety and …
Response: The Health and Safety Executive (HSE) intends to raise concerns about assessing the risk from hot surfaces and pipework at its Social Care Partners Forum and a national local authority …
Response: The Registered Nursing Home Association (RNHA) states the specific care home is not a member, thus they have no regulatory powers. They currently advise their members on the need for …
Responded
Vera Lillian Steel
Concerns: A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.
Overdue
Alan Smith
Concerns: A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by employees.
Overdue