Catalogue of failings that led to horror of Grenfell inferno
GRENFELL Tower residents should have been ordered to evacuate rather than told to stay in their flats as an inferno engulfed the doomed building, a public inquiry heard yesterday.
The blaze, the deadliest in Britain since the Second World War, started in the kitchen of a flat on the fourth floor just before 1am.
But flames ignited cladding on the outside of the building and leapt up – reaching the 23rd floor within 30 minutes.
Firefighters told people cowering inside to “stay put”, but a leading fire safety engineer commissioned by the inquiry found that “fatal failings” meant the strategy did not work.
Dr Barbara Lane said the strategy pursued by London Fire Brigade on June 14 last year failed within minutes of the fire starting.
She also concluded there was “a culture of non-compliance” at the 25-storey tower block.
In a report published for the first time, Dr Lane said: “I consider the stay-put strategy to have effectively failed by 01:26am. There was an early need for a total evacuation of Grenfell Tower.”
The inquiry heard that the block in north Kensington, west London, was encased in shoddy, poorly installed cladding.
Tests showed materials used, individually and together, did not comply “with the recommended fire performance” set out in guidance for a building of that height.
Dr Lane highlighted a litany of failings in the refurbishment of the block, which was completed just a year before the blaze.
Describing safety measures as “inadequate”, she said pipes used to transport water up the tower block were overloaded – leaving the upper floors, where most people died, vulnerable.
Abandoned
Fire doors to flats that should have resisted a blaze for 60 minutes lasted as little as 20 minutes.
Dr Lane said: “I conclude the entire system could not adequately resist the spread of fire over the walls having regard to height, use and position of the building.
“Specifically, the assembly failed adequately to resist the spread of fire to an extent that supported the required stay-put strategy for this high-rise residential building.
“There were multiple catastrophic fire-spread routes created by the construction form and construction detailing.”
The inquiry heard that the fire had climbed seven floors in seven minutes and 19 floors within 12 minutes.
The first 999 call was made at 00.54am, and for everyone to be safe a complete evacuation should have finished by 01:40am.
By 01.15am the principle of “stay put” had started to fail and by 01.26am had “substantially failed”.
The stairwell – the only escape route – was smoke-logged from 01.40am onwards.
The policy had been abandoned by 02.47am, one hour and 53 minutes after the first emergency call.
The hearing in central London was also played the first harrowing 999 call made by the tenant of flat 16 where the fire started.
Survivor Behailu Kebede told the operator: “Quick, quick, quick it’s burning.” The inquiry also saw a video in which one woman could be heard saying: “Oh my god” as burning debris rained down from the tower while another sobbed.
After the film was played, inquiry chairman Sir Martin Moore-Bick said: “It is truly shocking.” On a day of harrowing expert evidence, details emerged of how fixtures and fittings accelerated the spread of the fire.
Dr Lane chronicled a series of shortcomings in systems meant to mitigate fire risk.
Most fire doors at the entrance to the 120 flats were replaced in 2011 but neither they nor the original doors still in place complied with fire test standards.
Lifts did not work effectively, hindering the movement of firefighting kit and creating “unnecessary risk” to residents who could not use them to escape.
Windows in individual flats had no fire barriers around them and these openings were surrounded by combustible material.
This “increased the likelihood of that fire breaking into the large cavities contained within the cladding system”.
Dr Lane said the cladding system was “substantially to blame for the tragedy”.
“The building envelope itself was therefore a major hazard on the night of the fire...the consequences were catastrophic”.
Fifteen people living on the 18th to 22nd floors went up to the 23rd floor, and 47 of those who died were found on level 18 and above. No one died in flats on level 10 or
below. The Grenfell inquiry, scheduled to last 18 months, will hear from 533 individuals, of whom 21 are children who have not been named, 19 commercial bodies, eight public bodies and two trade unions.
It also heard from expert Jose L Torero, from the University of Maryland, who said the minor localised fire on the fourth floor was likely to have ignited the external facade before firefighters entered the flat.
Prof Torero said: “From this point forward the stay-put strategy was compromised and the evacuation of occupants an option to consider.”
He also concluded that factors “most likely linked to human action, error occurring either during the fire event or during design, construction and ongoing maintenance of the building” aided the spread of smoke and heat to the stairwell early on.
This “rapidly impeded” the escape of occupants around the building’s 12th floor and above the 20th.
He said: “Beyond this point, in the fourth stage, firefighting activities are governed by conditions in the building and are performed in an ad-hoc manner.
“There is considerable risk to those rescuing and being rescued, however egress remains the preferred option.”
In opening remarks Richard Millett QC, counsel to the inquiry, said: “The fundamental question which lies at the heart of our work is how, in London in 2017, a domestic fire developed so quickly and so catastrophically that an entire high-rise block was engulfed, and how it was 71 people lost their lives in a matter of hours, leaving family and friends in shock, grief and bewilderment.”
“The evidence currently suggests that around 187 occupants, about 64 per cent, had evacuated the tower by the time the stay-put advice was formally abandoned at 02.47am.
“The evidence also suggests that the rate of evacuation substantially slowed from 01.38am.
“Before that time 144 people had left the building and after the stay put guidance was changed an hour later only 36 people managed to escape the tower.
“It may well be that the withdrawal of the formal stay-put guidance at that stage was just that – mere formality in light of the number of occupants that had escaped safely before that time.
“On the other hand, it may be that the formal maintenance of that advice until 02.47am made all the difference between life and death.”
Mr Millett said London Fire Brigade commissioner Dany Cotton, who was at the scene from 02.29am told the inquiry in a statement: “I have never seen a building where the whole of it was on fire.
“Nobody has ever seen that. It was incredible. It was alien to anything I had ever seen.”
The Grenfell Tower blaze claimed the lives of 71 people. Another occupant died in January after a battle with a pre-existing condition, having never left hospital since the fire.
In a statement Grenfell United, the body representing bereaved families and survivors, said: “This is the beginning of a long road to justice. It is going to be difficult to see some organisations trying to defend their actions, but we have trust that, as the evidence emerges over the coming months, this inquiry will reveal the truth about how our community was treated before, during, and after the fire.”