Grenfell inquiry’s first phase report published
THE REPORT outlined that the building’s aluminium composite material (ACM) cladding was ‘the principal reason’ for fire spread, and was critical of London Fire Brigade (LFB).
The Guardian, The Telegraph, BBC News and Huffington Post reported on yesterday’s leak, with an inquiry spokeswoman stating this deprived ‘those most affected by the fire – the bereaved, survivors and residents – of the opportunity to read the report at their own pace’.
Chairman Sir Martin Moore-Bick was ‘very disappointed that someone has seen fit to disregard the confidential nature of the report’; it was ‘equally disappointing that media elected to publish what they would have been aware was subject to strict obligations of confidence’.
Participants were ‘entitled to expect’ others would not discuss it, so they could ‘each read the report undistracted’. The intention ‘was to provide those most affected [...] with an opportunity to read the report at their own speed without the distraction of public discussion and comment ahead of publication.
‘It was also intended to avoid a situation in which core participants learnt of the contents of the report from the media as a result of premature and unauthorised disclosure’, with the inquiry noting it ‘regrets the frustration that this has caused’.
Sir Martin called for ‘urgent action’ to improve high rise fire safety, and wanted recommendations ‘implemented without delay’. The fire was caused by an ‘electrical fault in the large fridge freezer’ of a fourth floor flat, and ‘occurred without any fault on the part of the tenant […] I am pleased to clear him of any blame, given that some people have unfairly accused him of having some responsibility’.
Fire spread and regulations
The ‘principal reason why the flames spread so rapidly’ was the ACM cladding and the ‘melting and dripping of burning polyethylene’; the ‘profoundly shocking’ spread was due to polyethylene cores with ‘high calorific value [that] melted and acted as a source of fuel’.
There was ‘compelling evidence that the external walls of the building failed to comply with requirements’, and did not resist spread but ‘on the contrary [...] actively promoted it’, though the inquiry did not intend to investigate ‘at this stage’.
LFB’s readiness was ‘gravely inadequate’, and its ‘preparation and planning’ fell short of ‘what should have been expected’. It was condemned for ‘serious shortcomings’ and ‘systematic failures’, with ‘institutional’ failures putting staff in an ‘invidious position’.
Personnel and systems were ‘overwhelmed by the scale’ of the fire, with ‘serious deficiencies’ identified in command and control, Sir Martin added: ‘I identify a number of serious shortcomings in the response of the LFB, both in the operation of the control room and on the incident ground. It is right to recognise that those shortcomings were for the most part systemic in nature. The “stay put” concept had become an article of faith within the LFB so powerful that to depart from it was to all intents and purposes unthinkable.’
Control room staff ‘undoubtedly saved lives’, but a ‘close examination’ revealed ‘shortcomings in practice, policy and training’. Supervisors ‘were under the most enormous pressure, but the LFB had not provided its senior control room staff with appropriate training on how to manage a large-scale incident with a large number of [fire survival guidance] calls’, while mistakes ‘made in responding to the Lakanal House fire were repeated’.
Those giving advice were ‘not aware of the danger of assuming that crews would always reach callers’, a ‘key lesson’ that should have been learned from Lakanal. Operators in the Stratford control room ‘too often treated what callers were telling them with scepticism, in some cases contradicting the caller’, often insisting the fire was only on floor four ‘contrary to what they were being told’.
Staff appeared ‘to have been unable to grasp the fact that it had spread rapidly up the building’, but were also ‘overwhelmed’ by the ‘unprecedented’ volume of calls. Many wrongly told residents help was coming ‘based purely on their personal expectations and assumptions’, which was ‘very dangerous, because the whole concept of fire survival guidance rests on a well-founded expectation that the caller will ultimately be rescued’.
Poor communication between the control room and site exacerbated the issue; however staff ‘saved lives’ and while there had been a ‘widespread failure’ to comply with regulations, the inquiry did not conclude that errors had cost lives.
Four of the first crew on site had 52 years of combined experience, but had not received training on risks posed by cladding or on fighting such fires. Sir Martin praised firefighters’ ‘extraordinary courage and selfless devotion to duty’, adding that ‘those in the control room and those deployed on the incident ground responded with great courage and dedication in the most harrowing of circumstances’. However, the lack of an operational evacuation plan was a ‘major omission’, and LFB had been guilty of an ‘institutional failure’ to inform firefighters about the risk of cladding fires.
On the night there was a ‘failure of command’ that meant firefighters with extended duration breathing kits were deployed ‘too slowly’, while watch manager Michael Dowden – commander for ‘most of the first hour’ – was criticised for ‘failing to consider’ evacuating sooner, and not ‘making efforts’ to discover what residents were telling control room operators.
An officer of his rank would not normally take charge, Sir Martin added, stating that ‘I have little doubt that fewer people would have died if the order to evacuate had been given by 2am’. LFB’s faith in the idea that fires would not spread was part of its ‘gravely inadequate preparation and planning’, while performance ‘fell below the standards set by its own policies or national guidance’.
Grenfell’s risk database ‘contained almost no information of any use’, with data from 2009 prior to refurbishment. Incident commanders were not properly prepared nor had been able to ‘seize control’ and change strategy: ‘None of them seem to have been able to conceive of the possibility of a general failure of compartmentation or a need for mass evacuation.’
‘Many lives could have been saved’ if officers had identified the fire was out of control sooner, and changed stay put advice, with commanders and firefighters not trained how to recognise the need for evacuation. The stay put change at 2.47am ‘could and should have been made between 01:30 and 01:50 and would be likely to have resulted in fewer fatalities. The best part of an hour was lost’.
Sir Martin also criticised LFB commissioner Dany Cotton for ‘remarkable insensitivity’ after she said she would not have changed the response, which showed LFB ‘is an institution at risk of not learning the lessons’ of the fire.
He added: ‘Quite apart from its remarkable insensitivity to the families of the deceased and to those who escaped from their burning homes with their lives, the Commissioner's evidence that she would not change anything about the response of the LFB on the night, even with the benefit of hindsight, only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire.’
Her evidence ‘betrayed an unwillingness to confront the fact that by 2017 the LFB knew (even if she personally did not) that there was a more than negligible risk of a serious fire in a high rise building with a cladding system’; a 2016 LFB slideshow about high rise cladding fires having ‘warned of a need to understand what products are being used in the façade system and their fire behaviour […] these could affect the way fires develop and spread in a building’.
Conclusions and recommendations
Among Sir Martin’s 46 recommendations were:
- a law requiring owners and managers of high rise residential buildings (HRRBs) to provide local fire and rescue services (FRSs) with information on external wall materials and building plans
- improve FRS high rise inspections and train crews to carry out ‘more thorough’ risk evaluations
- regular inspections of lifts ‘intended to be used’ by firefighters
- improved communications between FRS control rooms and incident commanders via a ‘dedicated communication link’
- develop national guidelines for ‘partial or total’ HRRB evacuations
- urgent inspections of fire doors in all multi occupancy residential properties
- improvements to National Police Air Service helicopter data, as images could not be viewed by LFB because ‘encryption was incompatible with its receiving equipment’