Litany of safety failings

Report finds a ‘culture of non-compliance’ was to blame for blaze which rapidly spread from one flat and claimed the lives of 72 people trapped in tower

‘I am particularly concerned about the maintenance regime of the active and passive fire protection measures’

RESIDENTS had repeatedly warned that Grenfell Tower was a “death trap”. A damning report made public yesterday proved they were right.

The official study by a leading fire safety engineer found a “culture of non-compliance” in fire safety was to blame for the rapid spread of the Grenfell Tower blaze that killed 72 people.

The report into the spread of flames and smoke, commissioned by the inquiry and written by Dr Barbara Lane, highlighted a litany of failings that included the use of combustible cladding; fire doors that did not work as they should; and an out-of-order fire lift that forced firefighters to use the stairs for moving heavy equipment.

The pipe system to get water to the top of the building to be used by firefighters also failed, as did a bespoke smoke removal system that did not conform to building regulations.

Dr Lane said in her report: “The number of non-compliances signify a culture of non-compliance at Grenfell Tower.

“I am particularly concerned about the maintenance regime of the active and passive fire protection measures.

“I note that multiple automatic systems, such as the control of the fire lift and the smoke ventilation system, appear not to have operated as required.”

The London Fire Brigade had put in place a “stay put” policy that was not removed until 2.47am, almost three hours after the emergency services were first called to a fire on the fourth floor in flat 16. But the advice for highrise residential buildings is reliant on a fire remaining contained in the flat where it broke out.

These are the failings identified by Dr Lane, which will be examined at the public inquiry that began taking evidence yesterday.

Cladding

Dr Lane’s report was highly critical of not only the material used in the aluminium “rainscreen” cladding system – designed to protect the building against the elements and to provide insulation – but also of the way in which it was installed. Grenfell Tower, which is 220ft tall, was refurbished at a cost of £10million, with work completed in 2016.

Dr Lane concluded the cladding system that was wrapped around the original concrete structure did not comply with building regulations, was not appropriate for such a tall building and created “multiple catastrophic firespread routes”.

She said the cladding was “non-compliant with the functional requirement of the building regulations”.

She had found “no evidence that any member of the design team or the construction ascertained the fire performance of the rainscreen cladding system materials”.

Her report said that building control had not been informed of its use and anyway did not understand how “the assembly would perform in a fire”. Neither the Tenant Management Organisation (TMO), which ran the building on behalf of the Royal Borough of Kensington and Chelsea, nor the London Fire Brigade, had carried out a risk assessment of its fire performance.

A further report commissioned by the public inquiry disclosed that no full-scale fire tests of cladding systems using the aluminium composite material panels were carried out before the fire.

Colin Todd, a fire engineer, said no BS 8414 tests were carried out using the material before the blaze. More than 300 high rise residential blocks have had similar cladding installed.

Windows

New windows installed as part of the tower’s renovation contributed to the “disproportionately high probability of fire spread”, Dr Lane concluded.

The UPVC windows were installed without fire resistant cavity barriers and were surrounded by combustible material.

The fire broke out in a kitchen in flat 16 on the fourth floor – in all probability in a fridge freezer – but spread through the kitchen window to the outside of the building. The fire rapidly spread up the east side of the building, reaching the top floor – the 23rd storey – by 1.30am, some 35 minutes after the fire brigade was first called.

The lack of fire insulation around the window had “increased the likelihood of that fire breaking into the large cavities contained within the cladding system” and provided “no means to

control the spread of fire and smoke”. The fire, once out of the window, spread vertically up existing columns clad in the aluminium panels but also vertically both above and below windows, and also “through the infill panels between windows”. Dr Lane wrote: “Both routes aided by the insulation materials surrounding the new window openings.”

The gap beyond the window was supposed to have fire-stops at intervals which would halt the advance of flames, but these were found to have been installed incorrectly.

The report added: “The windows were not provided with fire resisting cavity barriers. These unprotected openings themselves were surrounded by combustible material.

“Additional combustible construction materials were located in the room on the ceiling beside the window.

“Therefore, in the event of any fire starting near a window, there was a disproportionately high probability of fire spread into the rainscreen cladding system.”

Fire doors

Entrance doors to the flats, which should have resisted fire for 60 minutes, only lasted as little as 20 minutes, the inquiry report found. In some cases the closers did not work. Fire doors on the stairs also failed to do their job properly.

Poorly performing fire doors “contributed significantly to the spread of smoke and fire to the lobbies”, concluded Dr Lane. The fire expert found that all of the fire doors between the fourth and 23rd floor were “not compliant with fire test evidence relied upon at the time of installation”.

In 2011, the TMO replaced 106 flat entrance fire doors out of a total of 120 flats. The other 14 were not replaced because the leasehold had been bought from the council.

However, none of the doors were compliant, including the 14 which were not replaced in the refurbishment.

The fire doors had allowed smoke and flames to spread between the gap between doors and door frames, while multiple untested components in the doors themselves allowed fire to cross them and an unknown number of selfclosers failed.

Some fire doors were also held open by the firemen’s hoses rising up the building. In one case, a dead body prevented a fire door from shutting, allowing the flames and smoke to spread.

Dr Lane wrote in her report that this failure “would have materially affected the ability or willingness of occupants to escape independently through this space to the stair”.

It would have also hindered the ability of firefighters to rescue many people on the tower’s upper floors.

Another failure of an “unknown number of doors” to self-close after an occupant escaped would have allowed “immediate” spread of fire and smoke.

The lobbies could therefore not be used as a “safe air environment” by the fire service, which could not establish a rescue base – a bridgehead – at any storey above the fourth floor until 7.30am. Dr Lane said: “This greatly reduced the time available using breathing apparatus, and so the time available for rescue on the upper floors, and particularly above Level 15.”

Elizabeth Campbell, leader of Kensington and Chelsea council, said last night: “The footage we saw today is truly shocking, and the expert findings are extremely concerning.

“We are already replacing fire doors across the borough, and I have asked our senior officers to urgently review today’s reports further to see if there is more we need to do.”

Lift failure

A so-called fireman’s switch to allow the fire service to automatically ground a lift and take control of it was in place but not working, the report found.

The lifts in the building failed to perform effectively in the fire. That prevented firefighters using them to move heavy equipment up the building while also creating an “unnecessary risk” to residents who could not use them to escape.

Fire service notes suggest the “manual override” switch failed, which meant the lift could not be controlled by the emergency services.

As a result, firefighters were forced to climb stairs with heavy equipment such as breathing apparatus, slowing down rescue efforts.

It meant that survivors who reached the fourth floor bridgehead then had to be escorted down the staircase rather than placed in the lift, which would have saved time and manpower. But on the night of the fire that system failed to work as intended. Dr Lane said: “The system as designed and installed was non-compliant with the statutory guidance.”

The failure did not affect the initial attempt to put out the fourth floor blaze because there was no smoke in the stairwells and lobby areas at the time

However, Dr Lane added: “The coupling of a fire lift with an operational smoke ventilation system could possibly have had an impact on the ability to execute rescue.”

Failure of the water supply

Grenfell used a “dry fire main” – meaning the fire service needed to pump water into the tower to extinguish flames internally. In the alternative – “wet riser” – the system is already connected to the outside mains and there is no need for the fire service to connect the internal pipe to fire engine water pumps.

Dr Lane concluded that the dry riser system was “non-compliant with the design guidance in force at the time of the original construction and is also non-compliant with current standards”.

This stopped firefighters getting water to the upper floors as effectively as a wet main, which provides more pressure.

A wet fire main “could have enabled a faster initial response time” to the flat 16 fire, “which might have increased the chances of extinguishing the fire before it spread externally”.

‘The footage we saw today is truly shocking, and the expert findings are extremely concerning’