Grenfell Tower inquiry – phase one report NEWS
‘unprecedented’ volume of calls relating to the fire. Many control room staff also wrongly told residents help was coming ‘based purely on their personal expectations and assumptions’, which Sir Martin said was ‘very dangerous, because the whole concept of fire survival guidance rests on a well-founded expectation that the caller will ultimately be rescued’. Poor communication between
the control room and the site exacerbated the issue, with no television turned on to show images of the fire. However, he concluded that many staff ‘saved lives’ and while there had been a ‘widespread failure’ to comply with regulations, he did not conclude that errors had cost lives. Four experienced members of
the first crew on site had 52 years of combined experience, but had not received training on risks posed by exterior cladding or on techniques for fighting such fires. He praised the ‘extraordinary
courage and selfless devotion to duty’ of the firefighters who attended, adding that ‘those in the control room and those deployed on the incident ground responded with great courage and dedication in the most harrowing of circumstances’. However, the lack of an operational evacuation plan was a ‘major omission’, and LFB had been guilty of an ‘institutional failure’ to inform firefighters about the risk of cladding fires previously. On the night of the fire, there
was a ‘failure of command’ that meant firefighters with extended duration breathing kits were deployed ‘too slowly’, while watch manager Michael Dowden – commander for ‘most of the first hour’ – was criticised for ‘failing to consider’ evacuating the building sooner and not ‘making efforts’ to discover what residents were telling control room operators about the building. Sir Martin noted that an officer
of Mr Dowden’s rank would not normally take charge of such an
event, but concluded: ‘I have little doubt that fewer people would have died if the order to evacuate had been given by 2am’. The LFB’s faith in the idea that fires would not spread was part of its ‘gravely inadequate preparation and planning’, while its performance ‘fell below the standards set by its own policies or national guidance’. In turn, the risk database for the building ‘contained almost no information of any use’, with the data it did include dating from 2009, prior to the refurbishment. Incident commanders were not properly prepared, nor had they been able to ‘seize control of the situation’ and change strategy and, he continued: ‘None of them seem to have been able to conceive of the possibility of a general failure of compartmentation or a need for mass evacuation.’ He concluded that ‘many
lives could have been saved’ if officers had identified that the fire was out of control sooner and changed stay put advice. Incident commanders and firefighters were not trained in how to recognise the need for evacuation or on the dangers of combustible cladding. He noted that the stay put change, made at 2.47am, ‘could and should have been made between 01:30 and 01:50 and would be likely to have resulted in fewer fatalities. The best part of an hour was lost’.
Dany Cotton Sir Martin also criticised LFB commissioner Dany Cotton for ‘remarkable insensitivity’ after she said she would not have changed the response. ‘Quite apart from its remarkable insensitivity to the families of the deceased and to those who escaped from their burning homes with their lives, the Commissioner’s evidence that she would not change anything about the response of the LFB on the night, even with the benefit of hindsight, only serves to demonstrate that
the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire.’ Sir Martin added later, on the subject of Ms Cotton, that her evidence had ‘betrayed an unwillingness to confront the fact that by 2017 the LFB knew (even if she personally did not) that there was a more than negligible risk of a serious fire in a high rise building with a cladding system’, as a 2016 slideshow about high rise cladding fires had ‘warned of a need to understand what products are being used in the façade system and their fire behaviour […] these could affect the way fires develop and spread in a building’.
Report recommendations Sir Martin’s recommendations published in the report included that the following improvements should be made: • a law that requires owners and managers of high rise residential buildings (HRRBs) to provide local fire and rescue services (FRSs) with information on external wall materials and building plans
• improve FRS inspections of high rises, and train crews to carry out ‘more thorough’ risk evaluations
•
regular inspections of lifts ‘intended to be used’ by firefighters
• improved communications between FRS control rooms and incident commanders via a ‘dedicated communication link’
• development of national guidelines by the government for ‘partial or total’ evacuations of HRRBs
•
urgent inspections of fire doors in all multi occupancy residential properties
• improvements to data links provided by National Police Air Service helicopters, as images transmitted on 14 June 2017 could not be viewed by LFB on the ground ‘because the encryption was incompatible with its receiving equipment’ (Article continues overleaf)
www.frmjournal.com DECEMBER 2019/JANUARY 2020 9
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