Grenfell Inquiry: round-up of Sir Martin Moore-Bick’s phase one conclusions
Today, Sir Martin Moore-Bick, chair of the Grenfell Inquiry, has published his first phase report focusing on the night of the fire. Here, Inside Housing provides a round-up of his key conclusions from the report
What happened on the night of the fire, how did the fire spread and were mistakes made in the efforts to help rescue residents that lived in Grenfell Tower?
Over nearly seven months, Sir Martin Moore-Bick, chair of the Grenfell Inquiry, listened to evidence from dozens of those present on the night of the fire, as well as bereaved families, to get answers to these questions.
This morning, Sir Martin published his first phase report aimed at providing final conclusions on the events of 14 June 2017. He came up with a total of 10 main conclusions from the night.
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The cause and origin of the fire
The report makes clear that Sir Martin believes the fire started in the kitchen of flat 16 of Grenfell Tower, a conclusion supported by the residents of the flat, attending fire crews and expert testimony.
Slightly more contested is where in the kitchen the fire started. However, Sir Martin said that despite some “unanswered” questions, he is “in no doubt that the fire originated in the large fridge-freezer”.
An alternative theory from fridge manufacturer Whirlpool that the fire could have been started by a burning cigarette being thrown from a higher window was dismissed as “fanciful”.
In answering how exactly the fire started in the fridge-freezer, the report says the evidence “points strongly to an electrical fault having occurred within that appliance”.
Sir Martin made a point of noting that there was no evidence to suggest the fire was started deliberately or was caused by an improvised or inexpert attempt to repair a defect in the appliance. He also reiterated that Behailu Kebede, the resident of flat 16, bore no blame for the electrical fault.
The escape of the fire from the flat
In determining how the fire escaped from flat 16 into the exterior cladding system, the report considers evidence from a number of fire experts.
While each approached their analysis in different ways, all agreed on the idea that the most likely explanation was that the deformation and collapse of the uPVC window jamb enabled the fire to bypass the window and enter the cavity around the column and between the insulation and aluminium composite material (ACM) panels.
The report concludes that “the proximity of combustible materials to the interior of the compartment” then allowed the fire to spread.
While wider questions about the refurbishment of the tower and the suitability of building regulations are reserved for phase two of the inquiry, Sir Martin said he was happy at this stage to accept the evidence that there was a “disproportionately high chance” of fire spreading into the building’s cladding if it started near a window, because of the configuration and materials chosen.
The subsequent development of the fire
The report splits the subsequent spread of the fire at Grenfell into two main stages. First is the vertical spread to the top of the building, which, although rapid, was generally consistent with the way fires of this type are expected to behave.
The second stage occurred when the fire spread horizontally across the roof and downwards. This stage was considered more unusual.
The presence of ACM cladding with a polyethylene core was identified as the primary reason for both stages of the fire, and Sir Martin explained that this acted as a “source of fuel”.
Sir Martin dismissed the claims by cladding manufacturer Arconic that materials used in the insulation boards may have been to blame for the second stage, and instead said the melting of polyethylene from the cladding created a “waterfall” of burning.
The report says that phase two of the inquiry will pick this up by examining what was and should have been known by the construction industry and government, in regards to the dangers posed by these materials.
Internal penetration and the loss of compartmentation
In answering how smoke was able to spread into and through the interior of the building in the way it did, the report concludes that the building “suffered a total failure of compartmentation”. Comparisons were drawn with fires in other countries – in particular several large fires in Dubai, in which fewer casualties occurred because the buildings’ compartmentation was maintained.
However, at Grenfell there was evidence of a number of key active and passive fire protection measures that failed to operate as “effectively as could reasonably have been expected”, the report says.
Sir Martin said there is evidence to suggest that a number of factors are likely to have contributed to the loss in compartmentation, but there was a particular focus in his conclusion on the absence of effective self-closing doors, and the failure of doors to resist the spread of smoke.
However, the report says it is not currently possible to determine the extent to which other factors, including the movements of occupants and leakage through vents, led to the spread of smoke in the tower, if these had any impact at all. Again, this will be picked up as part of phase two.
Compliance with building regulations
While the inquiry did not originally intend to reach conclusions on this topic in its first phase, Sir Martin decided there was “no good reason” to omit some determinations in relation to the building’s external facade.
He said it would be an “affront to common sense” to suggest that the external building walls complied with the requirements of building regulations, which state that the external walls should adequately resist the spread of fire, giving regard to the height, use and position of the building.
The report concluded that instead of resisting the spread of fire, the walls “promoted it” and therefore did not comply with regulations.
Phase two will investigate the separate question of how those responsible for the design and construction of the cladding system were satisfied that the refurbishment of the building would meet regulations.
Planning and preparation
When considering the preparations made by the London Fire Brigade (LFB) for recognising and responding to a fire such as the one at Grenfell, several failings were identified.
For example, incident commanders had not received training on how to recognise the need for an evacuation or to organise one. Moreover, no tactical or contingency evacuation plans were in place for the tower were this scenario to occur.
Sir Martin said this failure was “surprising” given the long history of fires involving cladding on high-rise buildings both in the UK and abroad, of which the report gives many examples.
North Kensington fire crews were also criticised for the pre-fire inspections carried out on Grenfell Tower, for which they were also found to have received inadequate training.
The report says that information about the materials used in the cladding system could and should have been obtained by the LFB from Kensington and Chelsea Management Organisation (KCTMO).
The incident ground
Despite praising the bravery and commitment to duty shown by individual firefighters, Sir Martin said that this could not “mask or excuse the deficiencies in the command and conduct of operations”.
An analysis of the events on the night of the fire revealed a number of “significant systemic and operational failings” on the side of the LFB. These include the amount of time it took to override the ‘stay put’ policy. The report concludes that a decision to organise an evacuation could and should have been made between 1.30am and 1.50am and would likely have meant fewer fatalities. The report adds that the best part of an hour was lost before stay put advice was revoked.
According to Sir Martin, the early incident commanders failed to effectively seize control of the situation.
Meanwhile, those who were responsible for managing information from 999 calls failed to establish a clear system for receiving, recording and transmitting information, meaning much was left to the initiative and improvised methods of individual officers. The report brands this a “deplorable state of affairs”.
There are many reasons listed for the failures in communications, including problems with defective physical or electronic communication systems, which “significantly limited the efficiency of search and rescue operations inside the tower”.
The control room
A close examination of the control room’s operations on the night of the fire also revealed “shortcomings in practice, policy and training”. Control room operators did not know the circumstances in which callers should be told to evacuate or stay put, while supervisors had not been given appropriate training on how to manage a large number of calls.
Just as those on the ground were lacking important information from the control room, those in the control room did not know enough about conditions in the tower or the progress of responses to 999 calls, meaning they could not tell callers whether help was on the way.
It also found that when the ‘stay put’ advice was revoked and residents should have been told to leave, the operators did not understand that they had to give unequivocal advice to residents that they had no choice but to leave the building.
Finally, the report found a repeat of the mistakes made in responding to the Lakanal House fire, including the danger of call operators assuming crews would always reach callers.
The response of the other emergency services, the council and the tenant management organisation
While the report does not find evidence that any failings in the response from the police, ambulance services, the council or the tenant management organisation led to death or injury, it says that several important lessons could be learned for future major disasters in London.
For example, the police, the fire brigade and ambulance service all declared a ‘major incident’ without telling each other or the council. Therefore, the need for a co-ordinated joint response was not appreciated early enough.
Moreover, an emergency plan kept by Kensington and Chelsea Tenant Management Organisation (KCTMO) was found to be 15 years out of date.
As the Royal Borough of Kensington and Chelsea’s (RBKC) “contingency management plan” depended on information from KCTMO, the council’s plan was also found to be “partly ineffective”.
One particular cause for concern, according to the report, was the delay in obtaining plans of the building, which were not on site or in the fire brigade’s database.
The report criticises the response from KCTMO and its chief executive Robert Black. It describes Mr Black as believing that KCTMO had “no role” in the recovery effort and says it appeared he did not have “any clear perception of how he or the TMO could assist the RBKC or LFB”.
Isolating the tower from the gas supply
The report concludes that Cadent, the company that suppled gas to the tower, did an “excellent job” in finding the local gas mains and cutting off the supply of gas to the tower.
Sir Martin compliments the “inspirational leadership” of Cadent engineer Jason Allday, who attended the incident despite not being on call and at one point entered the basement to carry out an inspection.
When the gas was turned off nearly 24 hours after the first 999 call, the remaining flames died down almost immediately.
The Grenfell Tower Inquiry recommendations: phase one
Picture: Getty
Evacuation
There were no plans to evacuate Grenfell Tower available. Sir Martin Moore-Bick, chair of the Grenfell Inquiry, recommended:
- The development of national guidelines for carrying out partial or total evacuations of high-rise buildings – including protecting fire access routes and procedures for evacuating people who require assistance
- Fire services develop policies for partial or total evacuation of high rises
- Owner and manager be required to draw up and keep under review evacuation plans, with copies provided to local fire and rescue services and placed in an information box on the premises
- All high-rise buildings be equipped with facilities to enable the sending of an evacuation signal to the whole or a selected part of the building
- Owners and managers be required by law to prepare personal evacuation plans for residents who may struggle to do so personally, with information about them stored in the premise’s information box
- All fire services be equipped with smoke hoods to help evacuate residents down smoke-filled stairs
Fire doors
Sir Martin said it is apparent that “ineffective fire doors allowed smoke and toxic gases to spread through the building more quickly than should have been possible”, and that missing self-closers played an important role. He recommended:
- An urgent inspection of fire doors in all buildings containing separate dwellings, whether or not they are high rises
- A legal requirement on the owner or manager of these buildings to check doors at least every three months to ensure self-closing devices are working effectively
Sprinklers
Noting the recommendation from the coroner investigating the Lakanal House fire that the use of sprinklers be encouraged, Sir Martin said that some of his experts had “urged me to go a step further and to recommend such systems be installed in all existing high-rise buildings”.
He said that sprinklers have “a very effective part to play” in an overall scheme of fire safety, but that he had not yet heard evidence about their use. He said that he could make no recommendations at this stage, but that he would consider the matter in phase two.
Internal signage
Floor numbers in the tower were not clearly marked and markings were not updated when the floor numbers changed following the refurbishment. Sir Martin said that all high-rise buildings should have floors clearly marked in a prominent place, which would be visible in low light or smoky conditions. Given that not all residents of Grenfell could read fire information signs, he said this should now be provided in a means that all residents can understand.
Use of combustible materials
Sir Martin said the original fire in the kitchen was no more than an ordinary kitchen fire that spread to the cladding because of “the proximity of combustible materials to the kitchen windows” – such as the uPVC frames.
He said this is a matter that “it would be sensible” for owners of other high-rise buildings to check.
He said he would “add his voice” to those who have expressed concern about the slow pace of removal work for more than 400 other tall buildings in England with aluminium composite material cladding.
A total of 97 buildings in the social housing sector and 168 in the private sector have not yet seen the work complete. Sir Martin said the work must be completed “as vigorously as possible”.
He said particular attention should be paid to decorative features, given the crucial role played by the architectural crown at Grenfell in spreading the fire around the building.
Given the decision to ban combustible materials on new buildings last year, he did not call for further restrictions on their use.
Fire service: knowledge and understanding of materials in high-rise buildings
Sir Martin raised concern that junior firefighters were not aware of the danger of cladding fires, and that the London Fire Brigade (LFB) was unaware of the combustible materials used to refurbish Grenfell Tower.
He therefore recommended:
- That the owner and manager of every high-rise building is required to provide details of external walls and the materials used to the local fire service, and inform them of any changes
- To ensure that fire services personnel at all levels understand the risk of cladding fires
Plans
Sir Martin said that a lack of plans did not “unduly hamper” fire services at Grenfell, as each floor was laid out in the same way. However he warned that another building with a more complex layout could pose problems. He recommended:
- That owners and managers of high-rise buildings are required by law to provide paper and electronic versions of building plans of all high rises to local fire services
- To ensure the building contains a premises information box, including a copy of floor plans
Lifts
Firefighters were unable to use a mechanism that allows them to take control of the lifts on the night of the fire, hampering their progress and meaning residents could still use the lifts, “in some cases with fatal consequences”. Sir Martin therefore recommended:
- That the owner and manager of every high-rise building be required by law to carry out regular inspections of any lift required for use by firefighters and the mechanism that allows them to take control of it
Section 7(2)(d) of the Fire and Rescue Services Act
The judge was concerned that inspections of the tower by the fire service before the fire were not enough to meet their responsibilities under this act. He recommended:
- A revision of the guidance for the London Fire Brigade, and training for all officers above the rank of crew manager in inspecting high-rise buildings
Co-operation between emergency services
There was a lack of communication between each emergency service at Grenfell, with each declaring a major incident at different times without telling each other. Sir Martin recommended several changes to ensure better communication in the future.
Personal fire protection
Sir Martin decided not to issue a recommendation that individual flats be provided with fire extinguishers or fire blankets, noting concerns that this could encourage residents to fight fires rather than escape and call the emergency services.
Communication between the control room and the incident commander
While guidance calls for a “free flow” of information between a fire service control room and the commanding officer on the ground, that often does not happen. Sir Martin therefore recommended:
- A review of policies by the LFB on this matter, including training for all officers who could serve as incident commanders and senior control room officers.
- A dedicated communications link between the senior officer and the incident commander
Emergency calls
Even allowing for the pressure of the night, Sir Martin said that fire survival guidance calls were not handled in an “appropriate or effective way”. He therefore recommended:
- Amending of policies and training for control room officers
- That all fire services develop policies for multiple fire survival guidance calls
- Electronic systems to record and display calls
- A policy for managing a transition from ‘stay put’ to ‘get out’ and training for call handlers in delivering this change of advice
Command and control
Sir Martin said firefighters too frequently “acted on their own initiative”, resulting in a duplication of effort. He called for better policies to ensure:
- Better control of training and deployment
- Information is obtained from crews after they have deployed
Equipment
Sir Martin made some recommendations for improvements to fire service equipment, including radios and the command support system.
Testing and certification of materials
Sir Martin said this is an issue that will be investigated “early in phase two”, along with an assessment of “whether the current guidance on how to comply with the building regulations is sufficiently clear and reliable”.
He also said the inquiry would investigate whether a ‘prescriptive’ regime of regulation was necessary. However, as these issues have not yet been examined by the inquiry he did not make any recommendations.
