Grenfell Tower Inquiry Phase 1 Report

6 min readFeb 2, 2020

From October 2019: This is a summary of the Phase 1 Report of the inquiry. This article is split into sections for better understanding.

Grenfell Tower. Dan Kitwood/Getty Images

The long-delayed Grenfell Tower Inquiry Phase 1 Report was released recently. Chair of the inquiry, Sir Martin Moore-Bick, published assessments of the event and its causes, conclusions, and set out recommendations in the 1,000-page report.

Bereaved survivors and family members had made clear over the past two years (and prior to the fire in a blog post written by residents that received legal threats from the council for the post to be taken down) that the tower did not comply with regulations — hoping it would pave the way towards some form of justice and accountability.

ACM cladding

The report stated that the polyethylene inside the ACM (Aluminium Combustible Cladding) was the “primary cause” that facilitated the fire, Moore-Bike cited evidence that the plastic has “a heat of combustion similar to that of petrol or diesel fuel”.

Additionally, he made clear that the building was non-compliant with Building Regulation B4(1), stating, “whether one considers the rainscreen panels alone or the cladding system as a whole, or even the complete external envelope, including the original concrete structure, it is clear that the walls did not resist the spread of fire. On the contrary, they promoted it”.

This, of course, is a direct result of Kensington & Chelsea… and housing officials downgrading the fireproof cladding during the 2016 refurbishment in order to save £293,000 — a large cost, it seems, for the conscious jeopardization of working-class human life.

However, Moore-Bick said, “Although it was not originally my intention to reach conclusions in Phase 1 about the tower’s compliance with the Building Regulations, I can see no good reason why that question should not be determined now so far as it relates to the external facade.”

It is important to note that, to reiterate, the aim of this phase was not to draw conclusions, but to assess the event and causes.

Overall he said: “The building suffered a total failure of compartmentation. How the building came to be in that state is the most pressing question to be answered in Phase Two.”

Firefighters

Despite the “enormous courage and selfless devotion to duty” of firefighters the report extensively criticised the actions of firefighters on the night and highlighted, stating that “many more lives” would likely have been saved if the commander had suspended the ‘stay put’ policy and told residents to evacuate by 1.50am.

Unfortunately, the policy was dropped at 2.47am, but by then the fire was too strong and rendered it “too late to carry out a managed total evacuation”. Additionally, the report highlights other “significant systemic and operational failings”, noting “there is no evidence that any of the officers who attended the fire (with perhaps one exception) had received any training in the principles of evacuation, how to decide whether evacuation was necessary or how to carry it out safely and efficiently.”

In response to evidence provided by AC Dan Daly, then Head of the London Fire Brigade Fire Safety Regulation department, which was summarised by LFB Commissioner, Dany Cotton, in her oral evidence in which she states “the LFB would not develop a training package to respond to “something that simply shouldn’t happen”, Moore-Bick said she “betrayed an unwillingness to confront the fact that by 2017 the LFB knew that there was a more than negligible risk of a serious fire in a high-rise building with a cladding system.”

Adding, “a reluctance to accept that there was a risk that a fire of this kind and scale might occur in any building that had been provided with exterior cladding.” LFB’s high-rise firefighting policy (PN633) had a “major weakness” in its failure to make clear that, “although it refers to a potential need to evacuate a building to which a “stay put” strategy applies”, it doesn’t make clear to incident commanders that its existence should not deter them from “undertaking a full or partial evacuation if the behaviour of the fire justifies it.”

The report also stated that the LFB’s building safety inspections was “flawed”, branding it “a cause for concern” that no comprehensive assessment of Grenfell was carried out after the refurbishment.

Conclusions

The report makes clear that the fire started in the kitchen of a flat on the 16th floor. But it is still contested as to where in the kitchen the fire started, but Moore-Bick said that despite some “unanswered” questions, he is “in no doubt that the fire originated in the large fridge-freezer”.

In regard to how the fire escaped from the flat, the report concludes that “the proximity of combustible materials to the interior of the compartment” allowed the fire to spread. The report has grouped the subsequent spread of fire into two main stages: first is the vertical spread to the top of the building; the second stage is the unusual nature of the fire’s spread horizontally across the roof and downwards.

ACM cladding with a polyethylene core was identified as the primary facilitator of the fire in both stages. An examination of the control room’s operations on the night of the fire revealed “shortcomings in practice, policy and training”. Those on the ground lacked important information

Recommendations

Evacuation: “government develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings, such guidelines to include the means of protecting fire exit routes and procedures for evacuating persons who are unable to use the stairs in an emergency, or who may require assistance.”

“that fire and rescue services develop policies for partial and total evacuation of high-rise residential buildings and training to support them;”

“that the owner and manager of every high-rise residential building be required by law to draw up and keep under regular review evacuation plans, copies of which are to be provided in electronic and paper form to their local fire and rescue service and placed in an information box on the premises;”

Sprinklers: “The coroner who conducted the inquests arising out of the Lakanal House fire heard evidence about the installation of sprinklers and recommended that the government encourage housing providers responsible for high-rise buildings containing multiple domestic premises to consider fitting them. It is not surprising, therefore, that some core participants have urged me to go a step further and to recommend that such systems be installed in all existing high-rise residential buildings.”

Internal Signage: “The landings in the staircase at Grenfell Tower were not clearly marked with the relevant floor number and where floor numbers were marked they did not reflect the additional floors created during the refurbishment.”

“I, therefore, recommend that the owner and manager of every residential building containing separate dwellings (whether or not it is a high-rise building) be required by law to provide fire safety instructions (including instructions for evacuation) in a form that the occupants of the building can reasonably be expected to understand, taking into account the nature of the building and their knowledge of the occupants.”

Fire doors:

a. the owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) carry out an urgent inspection of all fire doors to ensure that they comply with applicable legislative standards;”

“b. that the owner and manager of every residential building containing separate dwellings (whether or not they are high-rise buildings) be required by law to carry out checks at not less than three-monthly intervals to ensure that all fire doors are fitted with effective self-closing devices in working order.”

Co-operation between emergency services: “I, therefore, recommend that the Joint Doctrine be amended to make it clear:

“a. that each emergency service must communicate the declaration of a Major Incident to all other Category 1 Responders as soon as possible;

“b. that on the declaration of a Major Incident clear lines of communication must be established as soon as possible between the control rooms of the individual emergency services;

“c. that a single point of contact should be designated within each control room to facilitate such communication;

“d. that a “METHANE” message should be sent as soon as possible by the emergency service declaring a Major Incident.”