Released this week, the first of two reports to be printed as components of the dual-phase inquiry chaired by Retired Honourable Sir Martin Moore-Bick detailed the events of the night of the fire, June 14, 2017.
The report detailed the Brigade’s preparedness as ‘gravely inadequate’, and noted a number of shortcomings in the LFB’s on-ground response and control room operations.
The report revealed that combustible cladding was the main reason for the fire’s quick spread.
The report says that the fire broke out just after 12 a.m. due to an electrical fault in a sizable fridge-freezer in the kitchen of Flat 16, occupied by Behadil Kebede (who, Moore-Bick says, bore no responsibility for the fire).
Before firefighters came on scene, the fire had penetrated the cladding.
After entering the cladding, the fire raced the face of the tower, around the tip of the building in both directions and down the sides until the coming flame fronts converged on the western face near the southwestern corner and consumed the whole building.
Moore-Bick said that aluminium composite panels bearing a polyethylene core stood as the core reason for the fire’s quick spread.
Moore-Bick said that the wall system did not adhere to building regulations declared in 2010.
In contradiction to requirements associated with those regulations for wall systems to resist the spreading of fire in regards to the height, use and position of the building, Moore-Bick said that the wall system on Grenfell promoted the fire’s quick spread.
Aside from cladding, Moore-Bick discovered other issues with the building.
Extractor kitchen fan units had a tendency to deform and become dislodged, supplying an entry point for the fire to come in from the exterior of the building to the inside.
Certain fire doors were left open or failed to close because they were built without effective self-closing devices.
The most severe criticisms were reserved for the London Fire Brigade, who the report said lacked in planning and preparation, on the ground throughout the incident and in the control room.
Says the report:
- Seasoned commanders and senior officers covering the fire had not been trained in regards to combustible cladding.
- Incident commanders were not trained in how to acknowledge the need for or organise an evacuation.
- No contingency plans were in place in regards to the tower’s evacuation.
- Essential information about the tower, stored on a LFB database, was incorrect or missing, making it useless for an incident commander.
- While attending firefighters showed bravery and devotion to duty, a good number of the first incident commanders on the scene were of relatively junior rank.
- During the fighting of the fire, information regarding the spreading of the fire was not shared, many physical or electronic systems like the command support system did not work properly, and officers did not inform themselves of conditions and operations in the structure.
- ‘Stay put’ advice was issued and a ‘stay put’ strategy was enacted when the tower should have been evacuated, resulting in the nearly an hour being lost before the advice was dismissed.
- While the control room staff received an unprecedented quantity of calls and undoubtedly saved lives, many shortcomings in the control room’s practice, policy and training were noted.
The report listed 35 recommendations in response.
These regard areas like information being made available to fire and rescue services regarding high-rise buildings and combustible cladding, communication amongst the control room and incident commanders, the practice of handling emergency calls, communication equipment maintained by crews at the fire, the evacuation of high-rise buildings, provision of fire safety information to high-rise inhabitants, and the inspection of fire doors, self-closing doors, and sprinkler protection.
Regarding the issue of combustible cladding, Moore-Bick stated that it was not necessary to recommend a ban on the usage of flammable materials in wall systems not adhering to the highest classification of standards under the European classification system in relation to fire known as Euro class A1– seeing that the government had banned the usage of some varieties of materials, whose classification in reaction to fire is lower than the level A2s1, d0.
He did stress the great importance of standing buildings with combustible cladding being remediated as soon as feasible.