The first phase of the Inquiry concluded with the publication of the official Phase 1 report by the Chairman Sir Martin Moore-Bick on 30 October 2019. The full report can be accessed here.
The report was divided into six parts which, broadly speaking, included an overview and narrative of the events leading up to the fire, findings regarding the origin of the fire and emergency services’ response, recommendations arising from those findings, and a look ahead to Phase 2.
Causes and development of the fire
The fire originated from an electrical fault in a fridge-freezer in Flat 16, for which the tenant of that flat bears no blame. This fire was described as ‘perfectly foreseeable’. From there, the fire most likely entered the cladding after the hot smoke deformed the uPVC window frame thus allowing the flames to reach the cavity between the cladding and the building.
From there the fire spread rapidly. It first traveled up the east face of the tower, then around the top of the building and back down the sides. The entire tower was engulfed within just three hours. Perhaps one of the most important findings was that the principal cause of this rapid spread was the aluminium composite material (ACM) rainscreen panels with polyethylene cores (ie the cladding), which acted as a fuel source with the melting and dripping polyethylene igniting fires on lower floors. The insulation boards behind the ACM panels, also part of the cladding system, as well as (potentially) components of the window surrounds, contributed to the rate and extent of vertical flame spread.
Exacerbating these problems were multiple failures of compartmentation. This included glass in the windows failing and kitchen extractor fans deforming, allowing the fire into flats; and failures regarding the fire doors. Some fire doors were left open, often due to a lack of self-closing mechanisms. Whilst some doors succeeded in holding back the smoke, others did not.
Although Phase 1 was not meant to include an examination of compliance with building regulations, the Chairman found that there was ‘compelling evidence’ of breaches regarding the external walls. Rather than resisting the spread of fire, taking into account the physical characteristics of the tower, the walls actively promoted it.
London Fire Brigade and emergency services responseThe report described the London Fire Brigade’s (LBF) preparation and planning for a fire such as the one at Grenfell Tower as ‘gravely inadequate’, citing several specific failings.
The senior officers and incident commanders who attended the fire had not received training regarding how to recognise the need for or how to organise an evacuation; nor had they received training in the dangers of combustible cladding. There was no contingency planning for the evacuation of the Tower. The LFB’s operational risk database, despite containing an entry on Grenfell Tower, lacked almost any useful information and was out of date, not having been updated since before the building refurbishment. In some cases, even basic information was wrong or missing.
Whilst acknowledging the courage and devotion to duty of the firefighters who attended the fire, the report found that the first incident commanders were not properly prepared.
None appeared to have conceived of the possibility of a compartmentation failure or need for mass evacuation. Once the failure of compartmentation and the scale of the fire became clear, the commanders failed to seize control of the situation or change strategy, including by failing to evacuate the building. The Chairman found that such decision should have been made between 1.30am and 1.50am. Instead, the LFB continued to follow the ‘stay put’ strategy without question, a decision which cost lives. There was a further general lack of training amongst junior firefighters regarding fires involving the tower’s combustible materials.
There were additionally several important communications failures. Information regarding internal spread of the fire and rescue operations results were not effectively shared with incident commanders. Physical and electronic communication systems did not work properly, making it difficult for example for firefighters inside the tower to communicate with commanders, and for commanders to communicate with police helicopters hovering above the tower.
Regarding other emergency services, the report concluded that whilst some aspects of joint protocols were successfully implemented, there were also a number of failures. These included communications failures, such as failing to share Major Incident declarations and a lack of coordination between different control room supervisors.
The report also discussed the role of the Royal Borough of Kensington and Chelsea (RBKC) and the Tenant Management Organisation (TMO). Although the TMO did have its own emergency plan, it was not activated and in any event was 15 years out of date and in several respects inaccurate. Despite this, the TMO possessed or had access to important information, such as building plans and lists of residents, that it failed to provide sufficiently quickly. The report was particularly critical of the TMO’s executives, finding that one, Robert Black, ‘did not appear to have any clear perception of how he personally, or the TMO as an organisation, could assist either RBKC or the LFB and he had no plan by which he could lead his staff’.
Remembering those who died
As the Inquiry opened with several days of hearings commemorating those who died in the fire, the report fittingly included an entire section remembering them. It lists the names of all those who died, followed by detailed information regarding their lives and contributions to the wider local community.
Although Phase 1 was limited to investigating the events during the night of the fire, the Chairman included numerous recommendations arising from his findings. These recommendations are wide-ranging and relate to matters such as fire and rescue services, evacuation of high-rise residential buildings, and the provision of fire safety information to residents. They included the following:
- The owners and managers of all high-rise residential buildings should be required by law to provide their local fire and rescue service with information about the design of its external walls and details of their construction materials;
- National guidelines should be developed for carrying out partial or total evacuations of high-rise residential buildings;
- The owners and managers of every residential building containing separate dwellings should urgently inspect all fire doors, and be required by law to carry out checks at not less than three-monthly intervals; and,
- The owners and managers of all high-rise residential buildings provide their local fire and rescue services with up-to-date plans of every floor of the building.
Phase 2: the road aheadThe focus of the Inquiry will now turn to ‘the decisions which led to the installation of a highly combustible cladding system on a high-rise residential building and the wider background against which they were taken’. It will also look at other ‘matters of particular concern’ arising from Phase 1. These matters include shortcomings regarding the LFB; testing and certification of materials; design and choice of materials; fire doors; lifts; smoke extraction systems; and the warnings of the local community and authorities’ response to the disaster. Phase 2 is broken down into eight distinct Modules. The Inquiry will not be looking at issues relating to stairs, gas and electricity.
Substantial further witness evidence will be presented, including from the private construction companies involved in the refurbishment of Grenfell Tower and the design of the materials used, as well as members of RBKC. Phase 2 will also look at some 200,000 pages of relevant documents, and reports from various experts (and the Inquiry will be able to instruct additional experts if needed).
The final order of oral opening statements has been published, and includes statements from Counsel to the Inquiry, Rydon Maintenance Limited, Arconic Architectural Products, the LFB, RBKC and the TMO, and the Mayor of London. These opening statements will fill the timetable from 27 to 30 January.
There is no set date by which Phase 2 will be concluded, but it is expected to last until the early months of 2021.
The hearings themselves have been moved from their previous location in Holborn, central London, to 13 Bishop’s Bridge Road, near Paddington, west London. They can be watched live on the Inquiry website, and will also be streamed at the Notting Hill Methodist Church.
How to cite this blog post (Harvard style) Bernardi, D. (2020). Grenfell Inquiry Phase 2: A Look Ahead. Available at: https://www.law.ox.ac.uk/housing-after-grenfell/blog/2020/01/grenfell-inquiry-phase-2-look-ahead (Accessed [date])