The Grenfell Tower Inquiry: Anatomy of a cover-upPart 2 By Alice Summers 4 March 2020

The following is the second part of a three-part series on the Phase 1 report of the Grenfell Tower Inquiry. Part one can be found here.

Phase 1 concluded last December. Phase two of the Inquiry opened this week, with witnesses from the corporations and organisations whose actions caused the deaths of 72 people granted immunity by the attorney general from any prosecution that might result from their testimony.

A litany of equipment failures or insufficienciesboth of the fire brigades own equipment and the abysmal internal and external state of the Grenfell Towervastly undermined every effort by firefighters to tackle the blaze. How firefighters came to be in this position, after decades of bipartisan central government cuts and deregulation efforts, is neither explored nor questioned by the Inquiry. Despite its account of the appalling conditions faced by firefighters on the night of the fire, where criticisms and recommendations are made, the report focuses almost entirely on the mistakes, real and imagined, of the London Fire Brigade (LFB). This is a transparent effort to shift the blame away from cost-cutting companies and complicit central and local governments.

The real criminals are sitting comfortably in their plush offices, government buildings and in Number 10 Downing Street. Successive Conservative and Labour governments laid the groundwork for the Grenfell Tower inferno over decades, with their cuts to fire services and relentless slashing of building and fire-safety standards, without the slightest concern for the lives and safety of working-class tenants in social housing and high-rise tower blocks.

The bonfire of regulations emboldened companies such as Rydon, Celotex and Harley Facades to deepen their single-minded pursuit of profit with no regard for safety, covering buildings in materials they knew full well to be highly flammable and toxic.

None of this would be known from reading inquiry chairman Martin Moore-Bicks Phase 1 report.

While acknowledging, at the beginning of its executive summary, that the main factor in the loss of life at Grenfell was the highly dangerous and toxic cladding that enveloped the building, the report devotes just two of its 18 concluding sections relate to cladding. A number of recommendations are made in a section on the Use of combustible materials and one on the Testing and certification of materials.

Although the report advises that the replacement of dangerous, flammable cladding on residential buildings should be done as quickly as possible and that the programme of remedial work should be pursued as vigorously as possible, Moore-Bick declines to elevate these suggestions to the level of one of the Inquirys official policy recommendations. Even so, under the terms of the inquiry set up under the 2005 Inquiries Act, these would not be binding!

The report does lay down clear and specific recommendations on numerous other mattersall related to the operations of the LFB. Some of Moore-Bicks recommendations include: that the LFB review its policies on communications between the control room and the incident commander; that the LFBs policies be amended to draw a clearer distinction between callers seeking advice and callers who believe they are trapped and need rescuing; and that the LFB develop policies and training to ensure better control of deployments and the use of resources.

The report makes a number of recommendations regarding the owners and managers of high-rise residential buildingsnone of which are enforceableincluding that they be required to supply the LFB with up-to-date plans of the building and let the LFB know what materials are used on the exterior of their buildings.

Despite the LFB requesting, on multiple occasions, that the Kensington and Chelsea Tenant Management Organisation (KCTMO)who managed Grenfell on behalf of the local Royal Borough of Kensington and Chelsea (RBKC) councilprovide them with plans of the building and a list of its occupants, this information was not provided to the fire brigade until 7:57 a.m. (hours after the fire broke out).

Many core participants in the Inquiry pressed Moore-Bick to immediately recommend, as a minimum, that the use of highly flammable materials be banned on all high-rise building exteriors. Moore-Bick rejected this.

It has been suggested by certain core participants, he states, that I should recommend that no materials be permitted for use in the external walls of high-rise buildings that are not of Euro class A1 (the highest classification of reaction to fire ...)

Pointing to a government consultation that had previously prohibited the use of some flammable materials on certain types of new buildings, Moore-Bick proceeded to dismiss these calls out of hand. Having regard to the outcome of that [government] consultation, and in the absence of any examination of the competing views, I do not think it appropriate at this stage for me to recommend any change to the regulations in this respect nor do I think it appropriate for me to recommend an immediate moratorium on the use of materials of Euro class A2 [the lower fire-safety classification], he wrote.

Tens of thousands of households are still living in buildings covered in flammable cladding, with more than 400 residential blocks coated in such materials, according to government data. As the FBU points out, According to the Hackitt review, there are 2,000-3,000 high-rise residential buildings (HRRBs) over 30 metres (10 storeys) and around 10,000 residential buildings over 18 metres (6 storeys) in England. The fire and rescue service in England is aware of more than 40,000 purpose-built flats of 4 storeys or more (11 metres), with more than 18,000 of those in London. The GTI [Grenfell Tower Inquiry] Phase 1 report should have done more for the residents of those buildings, as part of its promise that a Grenfell fire will never happen again.

Moore-Bick also rejected calls that he recommend the installation of sprinkler systems in all existing high-rise residential buildings, with reference to the financial burden on property owners and managers!

Acknowledging that sprinkler systems have a very valuable part to play in fire safety measures, he said he has heard no evidence about the use of sprinklers generally, their effectiveness under different conditions, or about the cost and disruption that would be caused by installing them in existing buildings (emphasis added).

The LFB, in its official response, welcomed many of the recommendations brought by Moore-Bick on firefighting and pledged to take every action we can to improve public safety. However, it criticised the lack of fire- and building-safety recommendations, expressing disappointment that measures we have been calling for are not in the recommendations, including the wider use of sprinklers in both new and existing buildings.

Moore-Bicks reluctance to make any criticism or recommendation in relation to fire-safety and building regulations, supposedly until he hears more expert evidence in Phase 2, does not extend to the LFB and their role on the night of the fire. In Chapter 28 of the report, he laid out his conclusions regarding the stay put policy in place at the tower. The failure of the LFB to revoke this policy until late into the events of the night is one of the main criticisms brought by Moore-Bick.

He stated: Once it was clear that the fire had spread out of control, that compartmentation had extensively failed, but that evacuation remained possible, a decision should have been made to evacuate the tower. Moore-Bick set this point in time at 01:50 a.m. in the early morning of June 14, 2017.

This is despite his admission that he received no expert evidence to inform his statement! In arriving at that conclusion, Moore-Bick wrote, I am conscious that I have received no expert evidence to guide me on it and that a qualitative judgement on the approach of the LFB at the Grenfell Tower fire might be thought to be a matter better reserved for Phase 2.

However, I am confident that, on the clear and extensive evidence about the events of the night that I have heard at Phase 1, I can and should reach that conclusion at this stage. It is not in the public interest to wait until the conclusion of Phase 2 to express a view about it.

Within the proper context, an examination of what the LFB did and failed to do on the night is entirely legitimate, including criticism of how long they stuck to the stay put advice telling residents to remain in their flats and await rescue. But such a review would take as its starting point the years of bipartisan cuts to the fire service that went unopposed by the Fire Brigades Union (FBU) and LFB management.

As the FBU itself points out, the LFB lost nearly 2,000 members of staff in a decade, with 5,500 people employed by the fire service at the time of the Grenfell Fire, compared to 7,200 ten years before.

During his time as London mayor, Prime Minister Boris Johnson imposed swingeing cuts on the LFB. Ten fire stations were closed across the capital, and some 14 firefighting appliances were lost, all of which had a devastating effect on the operations of the fire brigade, the FBU response states.

None of this is mentioned in Moore-Bicks report. The almost single-minded focus on the LFBs mistakes, and the lower standard of evidence Moore-Bick demands when it comes to making criticisms of the fire brigade, is calculated to obscure the truth, not reveal it.

As the report itself makes clear, tower blocks like Grenfell are not designed to enable a speedy and full evacuation of the building but are meant to be constructed to have entirely separate compartments that prevent or resist the spread of fire.

This assumption underlies the stay put strategy, standard procedure for high-rise blocks, with the aim of containing fires in individual flats and preventing chaotic stampedes through narrow and potentially smoke-filled passageways. The validity of stay put depends on effective compartmentation of the building, ensuring that the fires spread is restricted by fireproof obstacles like doors and windows.

At Grenfell Tower, the use of combustible materials massively compromised compartmentation, rendering stay put policy useless. Before firefighters had even extinguished the fire in its Flat 16 point of origin on the fourth floor, flammable materials used in window construction and external insulation and cladding in the 2016 refurbishment enabled the fire to spread to the outside of the building.

Much of the LFBs delay in revoking the stay put policy was due to their assumptions that the building would be compartmentalised and that flammable cladding could not have been used on a high-rise building.

In his witness testimony, Station Manager (SM) Andrew Walton recalled being told by LFB Watch Manager (WM) Dowden that the cladding was on fire. Until then, Walton had assumed it was the balconies that were ablaze, as he did not think that it was permissible to clad a building in flammable material. Several LFB witnesses said that they did not understand what was happening as the fire spread up the building and that buildings should not behave like that.

Moore-Bick concluded that this reflects the LFBs institutional failure to sufficiently educate firefighters on the dangers of cladding fires. This judgment ignores the fact that a fire of this nature was wholly avoidable, and that the installation of the flammable cladding was a criminally dangerous act. As expert witness Dr. Barbara Lane said, it was not reasonable to expect the fire brigade to fully mitigate the outcome of a fire where combustible cladding had been installed.

When questioned during the Phase 1 hearings on the lack of training for firefighters in recognising external cladding dangers, LFB Commissioner Dany Cotton responded that nobody could expect an incident like Grenfell Tower to occur or a building to be covered in such a highly flammable product and to fail so spectacularly.

She added that the LFB was not going to train for a space shuttle to land on the Shard.

While insensitive, this comment does point to the entirely unprecedented nature of the Grenfell fire. Even if one were to accept at face-value Moore-Bicks assertion that the LFB failed in its duty to provide guidance on the danger of cladding fires, responsibility does not lie with the capitals fire service, but with central government, whose responsibility it is to to provide regulations and authoritative guidance to direct local fire and rescue services about managing those risks, along with the necessary resources to implement the guidance, according to the FBU.

As for revoking the stay put policy, the report acknowledges that the failure of compartmentalisation made a full or even partial evacuation of the building an exceedingly difficult and dangerous task which, in some cases, could have put Grenfell Tower residents lives at even more risk. It states, Mass evacuation of the occupants of the tower would no doubt have presented serious risks to the lives of both residents and firefighters, given the internal layout of the building and the absence of any kind of communication system.

In response to a question as to why he did not immediately revoke the stay put advice, Deputy Assistant Commissioner (DAC) Andrew OLoughlin, who took over command at Grenfell at 1:56 a.m., told the Inquiry:

I would be revoking it for people who were in unaffected parts of the building. So not only would I be risking exposing them to any potential smoke in the staircase from the original fire, theyd also then be hindering the firefighters getting into the building to get to the floors where the fire survival guidance calls are coming. So, at that point, the primary focus was still to get firefighters to the fire survival guidance calls and to the top floors where the smoke may end up smoke-logging at the upper floors.

While more lives may have been saved had the stay put advice been revoked sooner, evidence from the report indicatesMoore-Bick declined to explicitly make this pointthat the window of opportunity for this was narrow and LFB commanders had little means for effectively conducting a full evacuation of the Tower.

Fire crews entered Flat 16 of Grenfell Tower at 1:20 a.m. and the building was only fully passable until 1:30 a.m., raising doubts as to whether there were enough firefighters at the scene by this time to have organised a full evacuation of the tower.

As there are no regulations that require a full public address system in high-rise buildings, the LFB had great difficulty in communicating with trapped residents, of whom many may not even have been awake or aware of the fire by 1:50 a.m., when Moore-Bick asserts that a full evacuation should have been ordered. Indeed, many residents did not make their first 999 calls until after 1:50 a.m.

Grenfell Tower had only one stairwell down which people could escape, and this was rapidly filled with thick, highly toxic smokedue to the appalling internal state of the building, including fire doors not working.

Specific and up-to-date information on which flats were inhabited by mobility-impaired residents should have been provided long in advance to the LFB by the TMO or RBKC, the report states, but was not. But little criticism of the council or TMO for their failure to provide such vital information is forthcoming from the report.

Even if this information had been provided to the fire brigade, the report acknowledges, it is unclear even with the benefit of hindsight how WM Dowden [who was incident commander at this time] could have achieved assisted evacuation of such occupants on the higher floors given the low numbers of EDBA [Extended Duration Breathing Apparatus] wearers he had at his disposal by 01.50.

Accordingly, WM Dowden was always going to be restricted in what he could do to achieve full evacuation by the limitations inherent in the building itself, the report concedes.

The FBUs response to the report correctly criticises the simplistic argument on the stay put policy presented by Moore-Bick. The FBU states that it does not accept the GTIs conclusion that a decision to evacuate should have been taken at 01.30 (or at least by 01.50).

The GTI has not made sufficient allowance for the actual conditions inside the building for what in reality would have been much more than simply an evacuation. For the initial commanders, during the first hour of the fire, it was not clearly established that compartmentation had extensively failed, but that evacuation remained possible.

It is easy in hindsight to say that the fire had spread out of control and that compartmentation had extensively failed half an hour after the LFB had been alerted to the fire. However, making that judgment was much harder on the night.

It continues: Grenfell Tower was designed for stay put. The GTI appears to believe that early incident commanders should have disregarded their training, ignored the actual conditions on the night and gambled on an untried, untested command strategy

When the GTI states that the fire spread out of control and that compartmentation had extensively failed by 01.30, such a conclusion would have surprised even the most experienced firefighter. The expectation would have been that windows and their surrounds would resist fire spread and that fire doors and other measures would limit the internal penetration of flames and smoke.

While an examination of the stay put policy is valid within the correct context, the building had been fatally compromised by the use of flammable materials long before the fire broke out, leaving the fire brigade in an impossible situation.

To be continued

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