Grenfell inquiry’s damning verdict on tragedy finds cladding was ILLEGAL and fire brigade planning was ‘gravely inadequate’ – as survivors blast fire chiefs for HIDING behind bravery of frontline heroes
- Fire chiefs held firm with a ‘stay put’ policy for more than hour, preventing people escaping the blaze in 2017
- It is thought that up to 55 of the 72 people who died in the Kensington fire were told to stay in their flats by LFB
- Inquiry chair Sir Martin Moore-Bick praised ‘bravery’ of firefighters but slams their bosses who led response
- Today’s report ends phase 1 of public inquiry, followed by phase 2 in January 2020 expected to take 2 years
- Nobody has been charged with any offences in relation to fire with police expected to wait until inquiry ends
- Whirlpool faces a multi-million pound legal fight after the Grenfell report found faulty fridge sparked inferno
Fire chiefs’ slavish refusal to evacuate Grenfell Tower cost many lives in a block encased in an illegal and combustible cladding that sped up the blaze that killed 72 men, women and children , the damning report into the Britain’s worst fire for a generation said today.
Inquiry chairman Sir Martin Moore-Bick has made 46 recommendations to help avoid a similar tragedy because of the extraordinary failings that contributed to the fire in west London on June 14 2017.
Today’s report into what caused the fire in Grenfell Tower was published this morning and describes the ‘lost’ minutes where the London Fire Brigade refused to drop its policy preventing people from being evacuated.
55 of the 72 people who died in the West Kensington fire had been told to ‘stay put’ in their flats inside the 14-storey block before the evacuation was finally ordered at 2.47am – almost two hours after a resident called 999 at 12.54am.
Sir Martin said: ‘That decision could and should have been made between 1.30am and 1.50am and would be likely to have resulted in fewer fatalities’, adding that their planning for a high-rise fire was ‘gravely inadequate’ and ignored lessons from the Lakanal House fire of 2009 where five died in similar circumstances.
Survivors today demanded fire chiefs including outgoing Commissioner Dany Cotton, who is retiring aged 50 on a £140,000-a-year pension, to stop ‘hiding’ behind the hero firefighters who battled the blaze that night – but Ms Cotton dug in this morning and said she was ‘disappointed’ with elements of the report including the naming of senior colleagues on duty that night.
Sir Martin has also concluded the cladding and insulation was illegal – paving the way for corporate manslaughter prosecutions – saying it was the ‘principal’ reason for the fire’s rapid and ‘profoundly shocking’ spread up to the top floor in just 30 minutes.
But with phase 2 of the inquiry on the technical aspects of the building expected to be completed in 2022, police are expected to wait until then to swoop, disappointing survivors and grieving relatives of the dead demanding justice.
The Grenfell Tower fire in North Kensington, West London, in June 2017 left 72 people dead and the report marking the end first phase of the public inquiry is out today
Rukayet Mamudu (left), 71, who survived the fire after carrying her son Tyrshondre (both left), 12, are among the families demanding justice. London Fire Brigade Commissioner Dany Cotton (right) is retiring at the age of 50 with a £2m pension – she has been heavily criticised by the inquiry
Dawn breaks at Grenfell Tower today on a landmark day for the families of the dead and those who survived the fire
Sir Martin Moore-Bick’s scathing conclusions over 1,000 pages
Sir Martin Moore-Bick, chairman of the Grenfell public inquiry,
Cause of blaze
It started due to an electrical fault in a fridge-freezer in flat 16 on the fourth floor. Flat owner Behailu Kebede will be absolved of any blame.
More than 200 survivors and bereaved families are suing Whirlpool, which supplied the Hotpoint model in the flat.
The London Fire Brigade’s preparation and planning for such a fire was ‘gravely inadequate’. Experienced incident commanders had ‘no training’ on the dangers of combustible cladding or on how to evacuate a high-rise block.
At the scene
Firefighters displayed ‘extraordinary bravery’ but incident commanders failed to recognise that a full evacuation may have been necessary.
If the decision to evacuate had been made it would have ‘resulted in fewer fatalities’.
Crucial information was not shared by senior officers.
There were ‘shortcomings in practice, policy and training’.
Call handlers did not always obtain the necessary information and were unaware of when to tell residents to evacuate.
The report criticises the London Fire Brigade’s commissioner for her ‘remarkable insensitivity’ after she told a hearing in September 2018 she would change nothing about its response to the fire.
The ‘principle reason’ that the flames spread so quickly up the tower block was due to the rain screen panels which ‘acted as a source of fuel’.
The insulation boards behind the cladding panels also accelerated the fire’s spread. These features were added during a refurbishment several months before the fire.
The failures of the building’s safety design were ‘rapid’. Many lobbies filled with fire 26 minutes after it started.
But Sir Martin Moore-Bick said stairs were ‘not absolutely impassable’ over an hour into it.
The tower’s external walls failed to comply with building regulations. There is ‘compelling evidence’ the walls did not ‘accurately resist the spread of fire’ but ‘actively promoted it’.
The evidence from the first phase of the inquiry ‘strongly suggests’ that ‘stay-put’ was an ‘article of faith within the LFB so powerful that to depart from it was to all intents and purposes unthinkable’, he said.
Sir Martin added: ‘I have little doubt that fewer people would have died if the order to evacuate had been given by 2.00am. The time between 2.00am and 2.47am was effectively lost.’ The judge said the absence of a plan to evacuate the tower was a ‘major omission’ in the LFB’s preparation.
The Grenfell Tower cladding did not comply with building regulations and was the ‘principal’ reason for the fire’s rapid and ‘profoundly shocking’ spread, the inquiry report said.
Once the fire had taken hold of the building’s exterior, it was ‘inevitable’ that it would find its way inside, Sir Martin said.
However, because there was no attempt to carry out a managed evacuation of the tower, this is less significant than the lack of training to help incident commanders recognise when this might be necessary, he said.
London Fire Brigade Commissioner Dany Cotton has been criticised in the report.
She said: ‘We will now carefully and fully consider all of Sir Martin Moore-Bick’s Phase 1 report and take every action we can to improve public safety.
‘Many of the recommendations are welcome and will need to be fully understood not only by London Fire Brigade, but by Government, every fire and rescue service and every residential building owner and manager across the country.
‘The report is focused on our response and it is right for our actions to be fully examined by the inquiry.
‘We welcome the chairman’s recognition of the courage, commitment and bravery of firefighters on the night, but we are disappointed at some of the criticism of individual staff members who were placed in completely unprecedented circumstances and faced the most unimaginable conditions while trying to save the lives of others.
‘On the evacuation of Grenfell Tower we note the chairman states he has received no expert evidence to guide him on reaching his conclusion and that a qualitative judgment on the brigade’s approach might be better reserved for Phase 2.’
Nobody has been charged with any offences since the inferno in June 2017 – despite Grenfell being encased in flammable cladding that acted like a giant firelighter when the blaze started because of a faulty fridge in a fourth floor flat.
But today’s report only marks the end of phase one of the probe – with phase two set to take another two years from January 2020 and detectives unlikely to charge those responsible until it finishes.
Damningly, the report says lessons had not been learnt from the Lakanal House fire of 2009. Three women and three children died in that high-rise blaze in Camberwell, South London which bore many similar traits and where victims were also told to stay put.
Karim Mussilhy, vice-chairman Grenfell United, who lost his uncle in the blaze, told the BBC’s Victoria Derbyshire programme: ‘We welcome it. It’s strong, it’s long awaited.
‘Sir Martin Moore-Bick has been very quiet throughout the inquiry, listening and hearing to everything, and this was his opportunity to come out strong and really set the tone for phase two and to restore some confidence back – not only in us, survivors and bereaved, but also the community and the rest of the country to a certain extent.
‘So we welcome this report and we think its findings are very strong. For me, what stands out the most is the building was illegal.
‘As of 2016, after the refurbishment was done, that building should not have been lived in. It was a death trap.
‘All of the people that were involved in the refurbishment and the management of that building will have to answer some serious questions.
‘Someone somewhere broke the law, and phase two will be about who broke the law. And hopefully this will bring some accountability.’
A graphic showing the people who died on the various floors of Grenfell Tower, most of whom were told not to leave their flats
The 72 confirmed victims who died in the Grenfell Tower fire. (top row left to right) Mohammad Alhajali, Ya-Haddy Sisi Saye, also known as Khadija Saye, Anthony Disson, Khadija Khalloufi, Mary Mendy, Isaac Paulos, Sheila, Gloria Trevisan, Marco Gottardi, (second row left to right) Berkti Haftom, Ali Jafari, Majorie Vital, Yahya Hashim, Hamid Kani, Jessica Urbano Ramirez, Zainab Deen, Nura Jemal, Jeremiah Deen, (third row left to right) Yasin El-Wahabi, Firdaws Hashim, Hasim Kedir, Deborah Lamprell, Ernie Vital, Sakineh Afrasehabi, Denis Murphy, Raymond Bernard, Biruk Haftom, (fouth row left to right) Yaqub Hashim, Mehdi El-Wahabi, Ligaya Moore, Nur Huda El-Wahabi, Victoria King, Mohamed Amied Neda, Maria del Pilar Burton, Hesham Rahman, Gary Maunders, (fifth row left to right) Alexandra Atala, Vincent Chiejina, Steve Power, Rania Ibrahim, Fethia Hassan, Hania Hassan, Fathia Ali Ahmed Elsanosi, Abufars Ibrahim (silhouette), Isra Ibrahim (silhouette), (sixth row left to right) Mariem Elgwahry, Eslah Elgwahry (silhouette), Mohamednur Tuccu, Amal Ahmedin, Amaya Tuccu-Ahmedin, Amna Mahmud Idris, Abdeslam Sebbar (silhouette) , Joseph Daniels (silhouette), Logan Gomes, (seventh row left to right) Omar Belkadi, Farah Hamdan, Malak Belkadi (silhouette), Leena Belkadi (silhouette), Abdulaziz El-Wahabi, Faouzia El-Wahabi, Fetemeh Afrasiabi, Kamru Miah, Rabeya Begum, (eighth row left to right) Mohammed Hamid, Mohammed Hanif, Husna Begum, Bassem Choukair, Nadia Choukair, Mierna Choukair, Fatima Choukair, Zainab Choukair and Sirria Choukair.
What is the five-year Grenfell Tower inquiry and why is it in two parts?
What was part one of the inquiry?
Chairman Sir Martin Moore-Bick wanted to find out the cause of the fire of June 14 2017 ‘as quickly as possible’ and how the fire was tackled to protect other residents of high-rise blocks on Britain. He wanted the work completed by April 2018 but it has now been completed 18 months later.
Campaign group Justice 4 Grenfell said firefighters ‘have been made scapegoats of Phase 1 while the ‘big’ players seem to have got off scot-free’.
What is part two?
This phase will focus on the technical aspects of the building, how it was refurbished and why its make-up accelerated the fire rather than slowed it.
It will start in January 2020 and will take up to two years to complete.
Businesses, architects and council chiefs will be in the firing line.
Harley Facades Ltd, which supplied the cladding panels, was the company behind the controversial refurbishment of the doomed Grenfell Tower in North Kensington.
Reynobond PE cladding was also used on Grenfell – which the Government said previouslu is illegal, although experts challenged this.
Even Reynobond’s manufacturer, Arconic, warns it is ‘crucial’ that Reynobond PE should not be fitted on tall buildings above 10 metres (32ft).
In the early stages of the refurbishment, a non-plastic type of panel named Proteus was proposed. But in the end, cheaper plastic ones named Reynobond PE were used.
Documents show Proteus panels, sold by KME Architectural Solutions, were initially specified for the Grenfell project by architects Studio E. Proteus panels are made with a non-flammable metallic honeycomb core.
Sir Martin will focus on the decisions that led to the highly combustible cladding being installed on the 24-storey tower block.
He will investigate the design of the cladding and choice of materials, the testing and certification of the materials, and the role of central and local government in promoting fire safety.
Other questions include whether fire doors complied with regulations, if the design of the windows during the refurbishment made it possible for fire to spread to the cladding, and whether lifts were properly maintained.
Survivors of the fire and bereaved family members will also hold a press conference this morning as the authorities face a pasting.
Moyra Samuels, from the Justice for Grenfell campaign group, slammed London Fire Brigade [LFB] and demanded answers, saying it was ‘obvious’ that families should not have been told to ‘stay put’ as the block burned.
She told ITV’s Good Morning Britain: ‘It was obviously for us on the outside that they should have been told to evacuate to have a mass evacuation. The LFB are going to have to explain that decision why there was such a huge delay’.
She added: ‘I think it’s quite concerning that there’s been an enormous amount of deficits in the LFB acknowledged in the report such as poor communication systems.
‘I think what we need is proper research I think the number of high risk buildings across the country with cladding is a massive concern.
‘We need some proper research with fire experts fire chiefs we need political will to explain in the case where stay put doesn’t work what should happen’.
Yesterday families condemned the London Fire Brigade boss for retiring with a £2million pension pot.
They claim fire commissioner Dany Cotton, who was heavily criticised by the official report into the tragedy which claimed 72 lives, has been ‘paid off for doing a deadly job’.
Prime Minister Boris Johnson said he hoped the report would bring ‘some measure of comfort’ to those directly affected by the fire.
He said: ‘They asked for the truth. We promised them the truth. We owe them the truth.
‘And, today, the whole country, the whole world, is finally hearing the truth about what happened at Grenfell Tower on the 14th of June 2017.
‘For the survivors, the bereaved, and the local community, this report will prove particularly harrowing.
‘Yet I hope it strengthens their faith in the inquiry’s desire to determine the facts of the fire – and in this government’s commitment to airing those facts in public, no matter how difficult they may be, and acting on them.
‘That commitment is absolute.’
The report, which was leaked yesterday, found that systemic failures by the LFB increased the number of deaths because it told residents to ‘stay put’ in flats for almost two hours after the first 999 call.
Miss Cotton was lambasted in the report for ‘remarkable insensitivity’ in her evidence to the public inquiry in September last year.
Sir Martin Moore-Bick, a retired judge who chaired the inquiry, said her attitude meant the brigade was at risk of failing to learn the lessons from Grenfell. He also highlighted her apparent lack of curiosity on arriving at the inferno at around 3am on June 14, 2017.
She was told the notorious ‘stay-put’ advice had just been abandoned, but asked no follow-up questions. Miss Cotton, whose annual pay package is worth £234,000, provoked anger when she told the inquiry she ‘would not change anything we did on the night’. The 50-year-old fire chief is retiring in April on a full pension estimated to be worth up to £2million after 32 years of service. She will have served as commissioner for three years and three months – six years fewer than her predecessor, Ron Dobson, who continued until he was 57.
Rukayet Mamudu, 71, who escaped in her dressing gown carrying her adopted 12-year-old son, said Miss Cotton should be stripped of her pension.
‘She should not get any pay-off,’ she said. ‘She should not be paid off for doing a deadly job. I am very angry. Dany Cotton should be made to pay the consequences of the fire brigade being so unprepared and for their inflexibility and failure to respond to events on the ground.’
Grenfell Tower in West London burns hours after the blaze swept through it in June 2017 – its cladding sped up the fire and helped it spread upwards
Nabil Choucair, who lost six family members in the blaze, said Miss Cotton’s pension pot was ‘like winning the lottery’. He said: ‘She doesn’t deserve it. Her not doing her job, or what she should have done, resulted in a lot of people dying.
Government rejects call for toxin exposure monitoring scheme after Grenfell fire
Mary Creagh, Environmental Audit Committee chairwoman
The Government has rejected calls for a monitoring programme to check residents’ exposure to toxic chemicals in the wake of the Grenfell Tower fire.
The parliamentary Environmental Audit Committee’s chairwoman Mary Creagh accused the Government of having ‘utterly failed’ residents for not implementing a ‘full health biomonitoring’ programme after the tragedy.
A report from the committee in July backed calls from experts and residents for such a programme, after concerns over environmental contamination caused by the fire in June 2017 in which 72 people died.
The parliamentary committee also recommended that local people with concerns about dust or residues in their homes should be offered the opportunity to have them tested.
The committee of MPs made the recommendations its report on toxic chemicals in everyday life, in which it described how residents have reported the emergence of the ‘Grenfell cough’ and health problems including vomiting, coughing up blood, skin complaints and breathing difficulties
Grenfell Tower in North Kensington, West London, in June 2017
A scientific study also found cancer-causing chemicals in samples taken from balconies within 100m of the tower a month after the blaze and ‘significant environmental contamination’ in the surrounding area, including in oily deposits collected 17 months after the tragedy.
Researchers concluded there was an increased risk of a number of health problems including cancer and asthma to those in the area.
But in its response to the EAC’s report, the Government did not accept the calls for a programme to monitor people’s exposure to toxins, saying it is not usually possible to determine if contaminants can be associated with such a fire.
It said Public Health England felt it ‘could cause unnecessary concern to an already distressed community’, and it would not provide reassurance as there was no pre-fire analysis for comparison.
And it highlighted ‘additional, ongoing environmental checks’ being carried out in and around the Grenfell Tower site, £50 million to fund long-term treatment for those affected by the fire and enhanced health checks offered by the NHS.
Mrs Creagh said: ‘The Government has utterly failed Grenfell residents in the aftermath of the disaster.
‘Rejecting our call for a comprehensive biomonitoring scheme – which would reassure Grenfell’s traumatised community – is another example of public authorities’ complacent and patronising attitude towards residents after the fire.’
On wider action to take toxic chemicals out of use, the committee also criticised the Government for failing to make swift progress to remove products such as flame-retardants used on home furnishings.
‘And she deserves an early retirement payout? I don’t think so. I don’t think she’s setting a good example. She’s just showing how if something goes wrong, this is how you get out of it – by retiring early. Whoever is responsible needs to be held accountable – not rewarded.’
Miss Cotton, who became the fire brigade’s first female commissioner in 2017, has previously compared the sight of flames ripping through the tower block to a ‘disaster movie’. She said the fire was ‘the most difficult thing’ she had dealt with in her career, saying that she has suffered memory loss and received counselling.
In her testimony, she also claimed no training could have prepared the fire crews, saying: ‘I wouldn’t develop a training package for a space shuttle to land in front of the Shard.’
Sir Martin’s report describes the lack of training at the fire services as an ‘institutional’ failure. He concludes: ‘Quite apart from its remarkable insensitivity to the families of the deceased and to those who escaped, the commissioner’s evidence that she would not change anything about the response of the LFB, even with hindsight, serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the fire.’
He also says Miss Cotton’s 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’.
Miss Cotton joined the brigade aged 18 as one of 30 female London firefighters.
The 935-page report into events on the night is published today. Sir Martin makes 46 recommendations following a two-year investigation. He says the ‘principal reason’ why the flames shot up the 24-storey high rise was the combustible aluminium cladding used in the refurbishment.
The report also concludes the fire started as the result of an ‘electrical fault in a large fridge-freezer’ in a fourth floor flat.
Part two of the inquiry examining the circumstances and causes of the disaster begins in January. An LFB spokesman said it would be ‘inappropriate’ to comment on the findings ahead of its official release.
Firefighters claimed yesterday that they are being made scapegoats after an official report into the Grenfell disaster condemned the actions of the London Fire Brigade.
They said that those who raced up the burning tower ‘merely did their best to save lives’ and that the ‘real culprits are yet to be held to account’.
And a fire union chief said the inquiry was ‘back to front’ because firefighters were being criticised ahead of those responsible for wrapping the building in flammable cladding.
The first part of the report into the tragedy concluded that systemic failures by the LFB caused a greater number of deaths.
It found that the slavish adherence to the controversial ‘stay put’ policy by fire chiefs prevented residents from escaping.
But firefighters yesterday said that the policy was introduced by the Government and accused ministers of evading criticism.
Matt Wrack, general secretary of the Fire Brigade Union, said: ‘The issues behind the Grenfell Tower fire go back 30 years or more and they lie at the heart of central government.
‘My frustration with this is that individual firefighters, including senior firefighters, are being subjected to a degree of scrutiny which Government ministers are avoiding.’
Appliance firm Whirlpool faces a multi-million pound legal fight after the Grenfell report found a faulty fridge-freezer sparked the inferno.
Investigators were unable to establish the exact nature of the electrical failure in the Hotpoint machine, supplied by the US manufacturer, but the report said Behailu Kebede, who lived in the fourth-floor flat where the blaze started, was not to blame.
The ‘relatively modest’ fire engulfed the building after burning through into the tower’s combustible cladding.
More than 200 survivors and bereaved families are suing Whirlpool in what lawyers have called ‘one of the largest product liability cases in history’. The action is also against cladding and insulation suppliers Arconic and Celotex. During the public inquiry, Whirlpool was accused of a ‘desperate’ attempt to dodge blame by suggesting the fire could have been caused by a cigarette.
Rajiv Menon QC, lawyer for Mr Kebede, called it a ‘transparent attempt by a multinational corporation to try to avoid liability and minimise reputational damage and financial loss’.
The report’s findings come after Whirlpool finally agreed to recall up to 800,000 potentially lethal tumble dryers in July. It had offered to modify at-risk machines – but the Daily Mail highlighted cases where fires started in dryers after they were fixed.
Timeline of tragedy: How the Grenfell fire unfolded and the five-year inquiry that it sparked
Here are the key moments that have defined the aftermath of the tragedy over the past three years.
– June 14 2017
At 12.54am, a call is made to the London Fire Brigade reporting fire has broken out in a fourth floor flat.
Barely half an hour later, at 1.29am, flames have now climbed to the top floor of the 24-storey block.
– June 28 2017
Retired Court of Appeal judge Sir Martin Moore-Bick is appointed to lead a public inquiry into the disaster.
He provokes alarm among survivors and bereaved families by initially expressing doubt that his investigation would be broad enough to satisfy all.
A public consultation is launched to determine the probe’s terms of reference.
– July 28 2017
The Government announces an independent review into building regulations will be led by Dame Judith Hackitt.
It is alleged that they are complex, unclear and leave enough wriggle room for contractors to cut corners on safety.
– August 15 2017
The terms of reference of the inquiry are announced.
It will include the cause of the fire and the actions of authorities before and after the blaze, but not broader concerns about the treatment of social tenants in Britain.
– September 19 2017
The Metropolitan Police announce a widening of their criminal investigation, with detectives now considering individual as well as corporate manslaughter charges.
– November 16 2017
More than five months on from the disaster, police say their final estimate for the number of people who died in the fire is 70, plus a stillborn baby.
– November 30 2017
A petition, backed by singer Adele, is set up urging Mrs May to appoint additional panel members alongside the inquiry chairman.
It is feared that Sir Martin will lack valuable first-hand experience of life as a social tenant in a multicultural neighbourhood.
– December 22 2017
Theresa May turns down the request from survivors and bereaved families to overhaul the public inquiry, saying Sir Martin has the ‘necessary expertise to undertake its work’.
– January 29 2018
Maria del Pilar Burton, a 74-year-old survivor known as Pily, dies in palliative care. She had been in a care home, unable to return to her husband Nicholas, since the fire.
She comes to be considered the 72nd victim of the fire.
– May 21 2018
The inquiry begins seven days of commemoration hearings to the dead, starting with a heartbreaking tribute to the fire’s youngest victim, stillborn Logan Gomes.
– June 21 2018
Firefighter evidence begins. It ends with Commissioner Dany Cotton telling the inquiry she would change nothing about her team’s response on the night of the fire.
Survivors and the bereave react with anger.
– July 18 2018
Scotland Yard announces detectives have carried out three interviews under caution and more will take place over the coming months.
– 12 December 2018
The first phase of the inquiry ends. Sir Martin announces the second phase is unlikely to begin until the end of 2019.
He also announces they are hoping to move to a west London venue for the next phase, after prolonged criticism from the Grenfell community about the inaccessibility of its current location.
– March 6 2019
No charges are likely to be brought in the criminal investigation into the Grenfell Tower fire for at least the next two years, police say.
The Metropolitan Police said it would be ‘wrong’ not to wait for the final report of the Grenfell Tower Inquiry which will come after the probe’s second phase.
Survivors call the wait ‘extremely frustrating and disheartening’.
– May 17 2019
The first report of the public inquiry, due to be released in Spring, is delayed until October. Campaigners call the delay ‘disgraceful’ . The start of the second phase is moved the January 2020.
– October 30 2019
Sir Martin Moore-Bick’s report is released, damning fire brigade bosses but praising the firefighters. He also concludes the cladding and insulation breached planning laws
The failures that meant lives were needlessly sacrificed: Litany of shortcomings led to 72 deaths in Grenfell horror
Fire chiefs are castigated in Sir Martin Moore-Bick’s 935-page report into the devastating blaze.
The London Fire Brigade was plagued with ‘institutional failures’ and its preparation for a Grenfell-style inferno was ‘gravely inadequate’, the retired judge found.
But he also ruled the tower’s cladding panels broke building regulations and actively helped spread the blaze. Among his findings:
How the blaze started
The Grenfell tragedy started with an electrical fault in the fridge-freezer of Flat 16, occupied by Behailu Kebede, pictured here leaving his flat on the day of the fire. The report said that Kebede was not responsible for what followed
The Grenfell tragedy started with an electrical fault in the fridge-freezer of Flat 16, but its occupant Behailu Kebede was not to blame, the report says.
Sir Martin said it was more important to establish ‘how the failure of a common domestic appliance could have such disastrous consequences’.
‘Inadequate’ fire planning
The firefighters who repeatedly ran into the burning building were praised for their ‘extraordinary bravery and selfless devotion to duty’.
But they were let down by having no training for a fire of such magnitude.
Sir Martin said: ‘The London Fire Brigade’s preparation and planning for a fire such as that at Grenfell Tower was gravely inadequate.’ Officers were faced ‘with a situation for which they had not properly been prepared’, and commanders had ‘no training’ on the dangers associated with combustible cladding.
Nor did they have any training on how to recognise the need for an evacuation of a high-rise block – let alone mount one. Sir Martin said there was simply ‘no contingency plan’ for evacuation.
The fire service’s database on large London buildings was ‘many years out of date’ and contained ‘almost no information of use’.
Safety design flaws
Firefighters spray water onto the Grenfell Tower block which was destroyed in a disastrous fire, in north Kensington, West London, Britain June 16, 2017
This picture of the Grenfell Tower six months after the blaze shows the damage to the external building. There was a catastrophic failure of ‘compartmentation’ – the safety design that supposedly stops fires spreading from flat to flat. The tower’s outside walls failed to comply with building regulations. There was ‘compelling evidence’ that the walls did not ‘adequately resist the spread of fire – on the contrary, they actively promoted it’
Flames and smoke billow as firefighters deal with a serious fire in the Grenfell Tower apartment block at Latimer Road in West London, Britain June 14, 2017
Pictured are the ashened lifts inside the Grenfell tower. Lives were probably lost because crews and 999 operators wasted ‘the best part of an hour’ telling the block’s occupants to ‘stay put’ in their flats – before realising the blaze was wildly out of control, the report says
Psychologist reveals ‘trauma’ suffered by Grenfell firefighters including one who had to choose to save a five-year-old child or a mother with a newborn baby
Psychologist Dr Shamender Talwar speaks on Radio 4 today
A psychologist who co-ordinated support for fireman battling the Grenfell Tower blaze has revealed how ‘traumatised’ crews were following the tragedy.
Dr Shamender Talwar, who is based in Kensington, West London, and also gave victims of the fire free therapy, said one firefighter had a choice between saving a five-year-old child or a mother with a newborn baby.
He told BBC Radio 4’s Today programme: ‘Basically the firemen risked their lives.
‘They were only told to do what they had to do, given instructions by their superiors to go in and save as many lives as possible. When they went in they had been traumatised.
‘There had been incidents where firemen had come down and basically had a choice of where they had seen a five-year-old on the left hand side and on the right hand side they see a mother with a newborn. What do they do?
‘They come back, and they come back traumatised, they come back scarred. And that’s why this has to be some sort of closure not just for the survivors but for the firemen too.’
There was a catastrophic failure of ‘compartmentation’ – the safety design that supposedly stops fires spreading from flat to flat.
Had compartmentation worked, it would have contained the blaze in the first flat until firefighters could put it out, enabling occupants elsewhere to ‘stay put’.
The ‘rapid’ failure of compartmentation meant the intensity of the heat shattered glass windows. Kitchen extractor fans were deformed and dislodged, giving the flames a deadly pathway. Fire doors at the front of flats failed in their job, filling lobbies with smoke.
Lives were probably lost because crews and 999 operators wasted ‘the best part of an hour’ telling the block’s occupants to ‘stay put’ in their flats – before realising the blaze was wildly out of control, the report says.
Incident commanders failed to recognise that compartmentation had failed and a full evacuation may have been necessary. They never gained control.
Sir Martin says of the stay-put strategy: ‘Once it was clear that the fire was out of control and that compartmentation had failed, a decision should have been taken to organise the evacuation.
That decision should have been made between 1.30am and 1.50am and would be likely to have resulted in fewer fatalities.’
He said ‘the best part of an hour was lost’ before the stay-put advice was revoked at 2.47am.
Many physical and electronic communication systems did not work properly on the night of the fire. Information sharing between the control room and the commanders on the ground was ‘improvised, uncertain and prone to error’.
Crucial information about the spread and extent of the fire was not shared by senior officers at the scene – and they were not kept abreast of vital information that was coming in to the 999 centre from stricken residents.
Control room staff swamped by 999 calls
Control room operators were in the ‘invidious’ position of being outnumbered by an unprecedented number of 999 calls on the night and ‘responded with great courage and dedication in the most harrowing of circumstances’, said Sir Martin.
Emotional Kensington firemen join bereaved family members including the parents and sister of Jessica Urbano, at the tribute wall near to Grenfell Tower in West London for a minutes’ silence
Daily Mail front page June 15, 2017 – Grenfell Tower FireFalling burning debris at the scene of a huge fire at Grenfell tower block in White City, London
Control room staff ‘undoubtedly saved lives’, but their operation was beset by ‘shortcomings in practice, policy and training’. Call handlers did not always obtain necessary details from those inside Grenfell, such as their flat numbers. Others did not know when to tell residents to evacuate.
Mistakes at a similar blaze were repeated
Damningly, the report says lessons had not been learnt from the Lakanal House fire of 2009. Three women and three children died in that high-rise blaze in Camberwell, South London which bore many similar traits.
Sir Martin said: ‘Mistakes made in responding to the Lakanal House fire were repeated.’
He said 999 operators were ‘not aware of the danger of assuming that crews would always reach callers’.
The tower’s outside walls failed to comply with building regulations. There was ‘compelling evidence’ that the walls did not ‘adequately resist the spread of fire – on the contrary, they actively promoted it.’
Outgoing fire chief Dany Cotton was criticised for her evidence to the inquiry in September last year. Sir Martin suggested her attitude meant the brigade was at risk of failing to learn the lessons from Grenfell.
He also highlighted her apparent lack of curiosity on arriving at the scene when told the stay-put advice had been abandoned.
Sir Martin wrote: ‘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, even with hindsight, only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the fire.’