Fire risk assessment failures
Systemic failures in fire safety, including inadequate risk assessments and unaddressed actions, posing risks to residents.
129 items
1 source
7 inquiries
Source spread
Where this theme appears
Fire risk assessment failures has been flagged across 1 independent accountability source:
129 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (129) — showing 50 strongest matches
61 — Studies on breathable air in the TSR
Recommendation: Studies should be carried out with the objective of assisting designers in predicting the breathability of air in a TSR where its external fire wall is subjected to a severe hydrocarbon fire (para 19.163).
Unknown
60 — Immediate assessment of smoke ingress
Recommendation: The regulatory body should ask operators which have not already done so to carry out forthwith an assessment of the risk of ingress of smoke or gas into the accommodation; and to fit smoke and gas detectors and implement ventilation …
Unknown
57 — Ventilation intakes and detectors
Recommendation: For the purpose of maintaining breathable air within the accommodation, it should be required by regulation that the ventilation air intakes should be provided with smoke and gas detectors and that on smoke or gas alarm the ventilation and dampers …
Unknown
56 — Protection of accommodation
Recommendation: The regulations and the related guidance notes should promote an approach to protection of the accommodation:- (i) in which external fire protection is provided both to prevent breach of the accommodation and to maintain breathable air within it (para 19.170); …
Unknown
54 — Immediate fire risk analysis by operators
Recommendation: The regulatory body should ask operators which have not already done so to undertake forthwith a fire risk analysis, without waiting for legislation (para 19.103).
Unknown
52 — Hydrocarbon fire test interpretation
Recommendation: The regulatory body should work with the industry to obtain agreement on the interpretation for design purposes of its interim hydrocarbon fire test and other similar tests. If in the view of the regulatory body there exists a need for …
Unknown
51 — Fire water deluge survivability
Recommendation: The ability of the fire water deluge system, including the fire pump system, to survive severe accident conditions should be a feature of the Safety Case (para 19.100).
Unknown
50 — Approach to fire and explosion protection
Recommendation: The regulations and related guidance notes should promote an approach to fire and explosion protection:- (i) which is integrated as between - — active and passive fire protection — different forms of passive fire protection, such as fire insulation and …
Unknown
49 — Fire risk analysis requirement
Recommendation: Operators should be required by regulation to submit a fire risk analysis to the regulatory body for its acceptance (para 19.90).
Unknown
46 — Studies on riser protection and SSIVs
Recommendation: Studies should be carried out with the following objectives:- (i) To achieve effective passive fire protection of risers without aggravating corrosion (para 19.22). (ii) To improve the reliability and reduce the cost of SSIVs so that it is more often …
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-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-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
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
P2-26 — Establish mandatory fire risk assessor accreditation
Recommendation: We therefore recommend 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. …
Words of: HM Government, Grenfell Tower Inquiry Phase 2 Report: Government response (CP 1248), presented to Parliament by the Deputy Prime Minister and Secretary of State for Housing, Communities and Local Government, 26 February 2025
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
P2-10 — Require fire safety strategy from registered fire engineer at Gateway 2
Recommendation: We therefore recommend that it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer (see below) to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any …
Words of: HM Government, Grenfell Tower Inquiry Phase 2 Report: Government response (CP 1248), presented to Parliament by the Deputy Prime Minister and Secretary of State for Housing, Communities and Local Government, 26 February 2025
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
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 …
Words of: HM Government (Ministry of Housing, Communities and Local Government), Grenfell Tower Inquiry Phase 1 Report: Government Response, January 2020 (published on GOV.UK 21 January 2020)
Gov response: The Home Office’s upcoming Fire Safety Bill will aim to clarify the scope of the Regulatory Reform (Fire Safety) Order 2005 – the ‘Fire Safety Order’ – to put beyond doubt that building owners or …
Accepted in part
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 …
Words of: HM Government (Ministry of Housing, Communities and Local Government), Grenfell Tower Inquiry Phase 1 Report: Government Response, January 2020 (published on GOV.UK 21 January 2020)
Gov response: The Home Office’s upcoming Fire Safety Bill will aim to clarify the scope of the Regulatory Reform (Fire Safety) Order 2005 – the ‘Fire Safety Order’ – to put beyond doubt that building owners or …
Accepted in part
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.
Words of: HM Government (Ministry of Housing, Communities and Local Government), Grenfell Tower Inquiry Phase 1 Report: Government Response, January 2020 (published on GOV.UK 21 January 2020)
Gov response: Sir Martin recommended that building owners or the responsible persons carry out urgent checks to ensure fire doors complied with current standards. MHCLG has recommended that all fire doors, including their closers, should be routinely …
Noted
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 …
Words of: HM Government (Ministry of Housing, Communities and Local Government), Grenfell Tower Inquiry Phase 1 Report: Government Response, January 2020 (published on GOV.UK 21 January 2020)
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
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 …
Words of: HM Government (Ministry of Housing, Communities and Local Government), Grenfell Tower Inquiry Phase 1 Report: Government Response, January 2020 (published on GOV.UK 21 January 2020)
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
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 …
Words of: HM Government (Ministry of Housing, Communities and Local Government), Grenfell Tower Inquiry Phase 1 Report: Government Response, January 2020 (published on GOV.UK 21 January 2020)
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
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 …
Words of: HM Government (Ministry of Housing, Communities and Local Government), Grenfell Tower Inquiry Phase 1 Report: Government Response, January 2020 (published on GOV.UK 21 January 2020)
Gov response: Sir Martin Moore-Bick’s Phase 1 report was exhaustive in detail and made a series of findings and recommendations relevant to government. As the Prime Minister and the Secretary of State for Housing, Communities and Local …
Accepted in part
70 — Availability standards for protective systems
Recommendation: Where a regulation imposes a requirement for a major emergency or protective system, such as a fire deluge system, it should be required that the operator should set acceptance standards for its availability (para 19.199).
Unknown
45 — Studies on inventory and pipeline connections
Recommendation: Studies should be carried out with the following objectives:- (i) To explore the feasibility of dumping in an emergency large oil inventories, such as those in the separators, in a safe and environmentally acceptable manner, so as to minimise the …
Unknown
5 — Design accidental events and acceptance standards
Recommendation: For the purposes of the demonstration referred to in para (iii) of recommendation 4, the accidental events are to be identified by the operator. A design accidental event is an event which will not cause the loss of any of …
Unknown
4 — Contents of the Safety Case
Recommendation: In furtherance of the objectives set out in para 2 above, the operator should be required to set out the following in the Safety Case:- (i) A demonstration that so far as is reasonably practicable hazards arising from the inventory …
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-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-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-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-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
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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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