Findings from the first phase of Grenfell public inquiry raise the stakes for Phase 2 in citing “compelling evidence” of the tower being too dangerous to live in.
The report says the “principle reason” why flames spread at such speed was the aluminium composite material (ACM) rainscreen panels with a flammable polyethylene core, which “acted as a source of fuel”.
That rapid spread was accelerated by the insulation boards behind the cladding panels and the window surrounds, both of which had combustible materials, the report finds – noting that features were added during the refurbishment of the building several months before the disaster.
The crown of the tower was also made from ACM panels – another architectural addition in the refurbishment – and the report references video evidence suggesting it was “primarily responsible” for the spread of the fire horizontally, as flames had not begun moving in that direction before reaching that level.
Compartmentation – the safety design supposed to ensure fire did not spread further beyond its origin allowing a stay-put policy to be in place – is said in the report to have failed “rapidly” as the intensity of the heat shattered glass windows with kitchen extractor fans deforming and dislodging as fire doors at the front of flats failed to hold back smoke.
Inquiry chair Sir Martin Moore-Bick said the external walls of the Tower – the focal point of the refurbishment work – failed to comply with building regulations, the report concludes.
There was, says Sir Martin, compelling evidence the walls did not adequately resist the spread of fire but instead “actively promoted it”.
Campaigners, survivors, and bereaved families hoped the building work would be ruled non-compliant.
Phase 1 of the Inquiry was limited to finding out exactly what happened on June 14 2017.
Phase 2 is focussed on establishing how the Tower came to be in a condition that allowed the disaster and is set to start in January to occur. The Inquiry continues to plan for Phase 2 hearings to commence in January 2020.
At around 1,000 pages – informed by around 50,000 documents submitted as evidence – the report draws damning conclusions on elements of the London Fire Brigade (LFB) response to the disaster.
While the report recognises “extraordinary bravery and devotion to duty” displayed by firefighters, the LFB’s preparation and planning for a fire of the magnitude of Grenfell is said to be “gravely inadequate”, with incident commanders and senior officers on scene having “no training” on the dangers associated with combustible cladding, nor how to mount an evacuation of a high-rise block.
This, the report says, was an “institutional failure”.
With no contingency plan for the evacuation of the tower, the LFB database on London buildings had information on Grenfell “years out of date” that did not capture changes made to the structure during refurbishment.
Incident commanders who initially oversaw the firefighting response were faced “with a situation for which they had not properly been prepared”, the report says.
As such, officers failed to recognise that compartmentation had failed and a full evacuation may have been necessary, nor did they ever gain control of the situation.
Of the stay-put strategy, the report says: “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 of the tower while that remained possible.
“That decision could and should have been made between 1.30am and 1.50am and would be likely to have resulted in fewer fatalities.”
Instead, as the report notes, stay-put was rescinded at 2.47am and, until then, was not questioned “notwithstanding all early indications that the building had suffered a total failure of compartmentation”.
The report also found that crucial information about the spread and extent of the fire was not shared by senior officers, while no system was in place for keeping commanders abreast of 999 call details.
Recognising control room operators faced an unprecedented number of 999 calls on the night of the disaster, the report says their operation was beset by “shortcomings in practice, policy, and training”.
Call handlers did not always obtain the necessary details from those within the building, including their flat numbers, while some were unaware of when to tell residents to evacuate.
The report referenced the 2009 Lakanal House fire in saying call operators on duty during the Grenfell fire were “not aware of the danger of assuming that crews would always reach callers”.
Rescue teams were unable to reach the upper floors of Grenfell Tower due to the intensity of the fire.
The report said the control room did not know enough about the worsening conditions in the tower, nor were officers at the scene receiving enough valuable information from the 999 calls, as the communication between the two hubs was “improvised, uncertain, and prone to error”.
Specific criticism is reserved for soon-to-retire LFB commissioner Dany Cotton, who told the inquiry she would change nothing about the LFB’s response.
The report singles out her “remarkable insensitivity” and suggested the LFB was at risk of failing to learn the lessons from Grenfell with such an attitude about its operation.
The report states this “only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire”.
Cotton is accused of an “apparent lack of curiosity” when she arrived at the scene at around 3am and was told the stay-put advice had been abandoned but asked no follow-up questions.
On the origin of the fire, the report absolved Behailu Kebede, occupant of the flat where the fire started, of any blame, saying it began with an electrical fault in a large fridge-freezer, the precise nature of which investigators were unable to establish.
The report says the exact cause is “of less importance than establishing how the failure of a common domestic appliance could have such disastrous consequences”.
Whirlpool, which supplied the Hotpoint model in Mr Kebede’s flat, is now at the centre of a major wrongful death lawsuit in the US brought by more than 200 survivors and bereaved families.
They are also suing Arconic, the firm that supplied the cladding used on Grenfell; and Celotex, which provided the insulation.
The report concludes the initial kitchen fire chewed through into the external cladding via the uPVC window jamb, where it reached a cavity between the insulation and the panels.
“A kitchen fire of that relatively modest size was perfectly foreseeable,” the report notes.