‘Stay put’ and preparedness
People died because the “stay put” policy was not lifted earlier, but the concept had “become an article of faith within the London fire brigade so powerful that to depart from it was ... unthinkable”.
Sir Martin Moore-Bick, the Grenfell inquiry’s chair, remarked that the way the London fire brigade (LFB) commissioner, Dany Cotton, had rhetorically asked in her evidence: “It’s all very well saying ‘get everybody out’, but then how do you get them all out?” demonstrated that the LFB had never itself sought to answer that question.
Faith in the idea that fires will not spread was part of the LFB’s “gravely inadequate preparation and planning”. “The performance of the LFB fell below the standards set by its own policies or national guidance,” he concluded.
Experienced commanders had no training in the dangers of combustible cladding, there was no contingency plan for the evacuation of Grenfell, the risk database for the building “contained almost no information of any use” and the information it did contain dated from 2009, before the catastrophic refurbishment.
On the ground at the fire
The first incident commanders at Grenfell Tower were not properly prepared and failed to seize control of the situation or 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,” Moore-Bick said. The shortcomings were “systemic” and “both personnel and systems were overwhelmed by the scale of the disaster”, but Michael Dowden, watch manager at North Kensington fire station, was among the junior staff criticised directly. He was first in charge on the scene and remained so until 1.50am and should have realised the fire had penetrated the building, and that compartmentation, which underpins the “stay put” advice had been breached. Dowden should have decided to evacuate the building, flooding the building with firefighters, knocking on doors to get people out, Moore-Bick said.
“Fewer people would have died if the order to evacuate had been given by 02.00,” said Moore-Bick.
There were “serious deficiencies in command and control”, he said. Senior officers arriving later failed to give sufficient practical support or inform themselves quickly enough of conditions and operations within the building and “the best part of an hour was lost”.
999 calls
Operators in the LFB control room in Stratford, east London, sometimes refused to believe desperate victims about smoke and fire as they were “overwhelmed” by an unprecedented volume of emergency calls from Grenfell residents.
Operators “too often treated what callers were telling them with scepticism, in some cases contradicting the caller.” Often they “insisted the fire was on floor four, contrary to what they were being told by the caller. They appear to have been unable to grasp the fact that it had spread rapidly up the building.”
Many wrongly told residents help was on its way and the advice was based purely on their personal expectations and assumptions. “That was very dangerous, because the whole concept of fire survival guidance rests on a well-founded expectation that the caller will ultimately be rescued.” There was poor communication between the control room and the fire and no TV was turned on to show images of the fire.
Many saved lives. “A notable example is the courage and calm of Heidi Fox in coaxing Marcio Gomes and his family … down from floor 21.” While there was “widespread failure” to comply with regulations, Moore-Bick did not conclude errors cost lives.
Construction industry
Moore-Bick said the rapid spread of the fire across Grenfell Tower remained “profoundly shocking” and in one of his most significant findings, ruled the 2014-16 refurbishment of the tower breached building regulations. This will pile pressure on the companies involved in the works ahead of the inquiry’s second phase. The main reason for the spread of the fire were the cladding panels, manufactured by Arconic, “with polyethylene cores, which had high calorific value, melted and acted as a source of fuel for the growing fire”. The design of the refurbishment, overseen by Studio E Architects, as well as the insulation materials made by Celotex and Kingspan, also contributed, he said.
Recommendations
A law requiring owners and managers of high-rise residential buildings to provide their local fire and rescue service with information about external wall materials and building plans.
Fire brigade inspections of high-rise buildings to be improved and crews trained to carry out more thorough risk evaluations. Regular inspections of lifts intended to be used by firefighters are needed.
Communications between fire brigade control rooms, where emergency calls are received, and incident commanders must improve and there must be a dedicated communication link.
Government should develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings.
Fire doors in all multi-occupancy, residential properties should be urgently inspected.
Improvements should be made to the data links provided by helicopters of the National Police Air Service. Pictures transmitted on the night of Grenfell could not be viewed by the LFB because the encryption was incompatible with its receiving equipment.
