Grenfell Tower inquiry: Catalogue of failures laid bare shows 'stay put' advice untenable, fire lift broken and cladding not tested for resistance to flames

'No evidence yet' that designers, builders, landlord or fire brigade assessed cladding's resistance to flames, Dr Barbara Lane says in new report

Jon Sharman
Monday 04 June 2018 20:20 BST
Photos show the extent of damage inside the Grenfell Tower flat where the fire started

A catalogue of failings helped fire to spread at Grenfell Tower and hampered efforts to save lives, the public inquiry into the disaster has heard, adding up to what one expert called a “culture of non-compliance” with fire safety rules.

A non-functional fire lift for emergency workers, wrongly installed barriers against flames inside the building’s cladding and the widespread use of combustible material all played their part in a fire that killed 72 people, a damning report by Dr Barbara Lane found.

In addition, the “stay put” advice to residents had “effectively failed” less than 40 minutes after the outbreak of the fire, and there was “an early need for a total evacuation” due to the rapid spread of flames across the face of the tower, the document that ran to hundreds of pages said.

Moreover, no one in authority appeared to have investigated the potential fire risk posed by the cladding materials, which in any case did not comply with regulations, the report found.

Dr Lane wrote: “I have found no evidence yet that any member of the design team or the construction team ascertained the fire performance of the rainscreen cladding system materials, nor understood how the assembly performed in fire.

“I have found no evidence that Building Control were either informed or understood how the assembly performed in fire.

“Further, I have found no evidence that the Kensington and Chelsea Tenant Management Organisation (KCTMO) risk assessment recorded the fire performance of the rainscreen cladding system, nor have I found evidence that the London Fire Brigade (LFB) risk assessment recorded [its] fire performance.”

Dr Lane said she was awaiting further evidence, and elsewhere in her report suggested LFB had not been told the cladding was combustible. Because of that, there was “no evidence that they understood the need to change their standard pump response for an intended internal high-rise residential fire”.

Last year the Metropolitan Police, which is conducting a criminal inquiry into the disaster, advised Kensington and Chelsea council not to release documents showing how KCTMO responded to an LFB warning about potentially flammable cladding.

The council said it was withholding the documents, requested by The Independent under freedom of information laws, in the public interest, a decision which campaigners said “makes no sense”.

Inside the kitchen where the blaze began

1. Tall fridge-freezer: The appliance originally blamed for starting the fire was reduced to a charred shell. Experts have since cast doubt on that original conclusion.

2. Kitchen window: This was where the fire ate through combustible material in the window frame and took hold in the new external cladding.

3. Old freezer: The kitchen had another, smaller freezer and a separate fridge near the window.

4. Cooker: A white hob and double-oven unit was located next to the tall fridge.

5. Washing machine: One of several other items left nearly unrecognisable by the flames.

6. Baton associated with sliding doors: This track would have been built for sliding doors that separated the living room from the kitchen.

Grenfell Tower inquiry: How the fire developed and 999 call

Overall, Dr Lane wrote, there appeared to be “a culture of non-compliance at Grenfell Tower” in terms of fire safety.

She identified a string of shortcomings in systems designed to mitigate fire risk – a failure to stick to regulations including in the block’s lifts, ventilations systems, fire mains and fire doors. These would have hindered the escape of residents on the night of the fire, as well as the effort to tackle the fire, while also worsening the spread of smoke.

KCTMO replaced 106 of the entrance doors to Grenfell Tower’s 120 flats in 2011, but none of the doors were compliant with fire test evidence relied upon at the time they were fitted. They may only have held out against the flames for 20 minutes, Dr Lane found, instead of the 60 minutes set out in current guidance.

The broken fire lift, she said, was not “directly linked” to the failure to control the spread of fire, but “indirectly contributed in that it affected the operations of the fire service, who rely on firefighting lifts to transport equipment, personnel and exercise rescue”.

When it came to the fire brigade’s “stay put” advice, Dr Lane said she was “unclear about the basis” for not having ended the advice sooner on the night of the disaster, and “particularly concerned” about a 41-minute delay after 2.06am on 14 June last year – the time at which a major incident was declared.

Yet there was no all-building alarm available to LFB to use to signal residents that a full-scale evacuation was required. In addition, such a system is not mandated by law in the UK for high-rise residential buildings, she said.

Other problems inside the building included a dry fire main that was not compliant with regulations and lacked the capacity to allow effective firefighting, and a smoke dispersion system that did not work properly.

The inquiry into the Grenfell tragedy, following a week of testimony by the relatives of those killed, published five expert reports on Monday morning including Dr Lane’s.

A second report, by Professor José Torero, another fire engineer, found that LFB’s “stay put” advice was appropriate only in the first phase of the fire, before external cladding panels caught light.

The firefighters, the experts’ reports suggest, were outflanked by the flames as they tore through the cladding and into more flats.

While fire had begun to spread to the top of the building and to penetrate flats on multiple floors, evacuation of residents was still possible via stairwells which smoke had not yet reached, Prof Torero, of the University of Maryland, said.

At this stage, he added, evacuation would not be risk-free but “can be considered a better strategy than ‘stay put’.”

Richard Millett QC, the counsel to the inquiry, said that by 2.47am when “stay put” was officially abandoned some 187 Grenfell occupants, or about 64 per cent, had evacuated. Only 36 people made it out after the guidance was changed.

On Monday the inquiry was shown footage of the fire taking hold of Grenfell Tower, which was described by chairman Sir Martin Moore-Bick as “truly shocking”.

The time-stamped videos showed how flames tore across the face of the building in mere minutes. From the time of the first clip, at 1.08am, the inferno took less than 20 minutes to reach the towers’ upper floors on one side.

Footage taken by residents and people in the area showed fiery debris falling from the block as one woman could be heard saying: “Oh my God.”

Another could be heard sobbing as it became clear the fire was out of control.

The fire’s beginnings and how it spread  

Firefighters’ evidence revealed from moments after flames burst through Flat 16’s window  

  • The initial 999 call was made by Behailu Kebede at 12.54am, and he told the operator: “Quick, quick, quick, it’s burning.” He reported seeing smoke near his fridge-freezer which was near the kitchen window. London Fire Brigade initially deployed four fire engines.


  • Experts separately concluded that the blaze began somewhere in the kitchen of Mr Kebede’s flat, number 16 on the fourth floor, but the precise cause has not yet been determined.


  • Firefighter John O’Hanlon was part of the second crew to enter Flat 16. Describing the scene in the kitchen he said: “You wouldn’t recognise it as a fridge, just a charred rectangle with a bit of melted stuff at the bottom that was still alight. The window had gone by then, broken ... Even the frame wasn’t there and we noticed that it was on fire.” He said he tried to spray the window surround with the fire hose – while leaning out of the window – but to no effect.


  • Professor José Torero’s report to the inquiry concluded the kitchen fire probably ignited the external facade before firefighters entered the flat.


  • Dr Barbara Lane said that detailing around the new and old windows during Grenfell Tower’s refurbishment had “increased the likelihood of a fire breaking out of the flat and ... into the large cavities contained within the cladding system”. She added: “Those cavities contained combustible materials.”


  • Dr Lane also reported that fire-stopping barriers between cavities – horizontal and vertical – had been installed incorrectly. She said no evidence had been provided that they were even tested for performance in a cladding system like that adorning Grenfell Tower. The windows themselves were not equipped with fire-resisting barriers, leading to a “disproportionately high probability of fire spread into the rainscreen cladding”, she added.


  • Professor Luke Bisby, in another report, agreed that the flames began eating into the tower’s east facade before firefighters entered Flat 16. He said the fire chewed through the plastic window frame, weatherproof membrane and thermal insulation in Mr Kebede’s kitchen, and noted all those items were “installed during the 2012-16 refurbishment”.


  • Video shown to the inquiry, and seen around the world in the early morning of 14 June last year, captured how flames consumed the combustible cladding both vertically and horizontally to eventually engulf the tower. Dr Lane wrote: “Once a fire penetrated into the rainscreen cladding system, there was no provision ... to impede the spread of fire and smoke around the building. This created the means for a catastrophic condition.”


  • Dr Lane reports, effectively, that the crews first called to the fire were caught out by the design of the new cladding; they were very quickly fighting on two fronts. She said: “I do not consider it to have been feasible, without prior warning, to implement effective external firefighting to level four in the very early stages”. As for afterwards, she said, that must be investigated by “the appropriate experts”.

The inquiry also heard that the fire may not have been caused by a Hotpoint fridge-freezer as authorities had previously announced.

Last June the Met said it had identified the Hotpoint FF175BP model fridge as the epicentre of the blaze, and the government ordered an immediate examination. At the time Hotpoint said it was treating the discovery as “a matter of utmost urgency” after witnesses reported a neighbour as having said his fridge “exploded” on 14 June.

But a report by forensic scientist Professor Niamh Nic Daeid now says the fire’s exact origins are “undetermined”, while tracing it to “in or around the area” of the appliance. Separately, Professor Luke Bisby said there was “insufficient evidence” the fridge started the fire.

He wrote: “Some evidence exists to support a hypothesis that the fire started in the south-east side of the kitchen and in the general area of the Hotpoint FF175P fridge-freezer, however, there is currently insufficient evidence, even based on a balance of probabilities, in my opinion, to support the hypothesis that the fire originated in the fridge-freezer, and to exclude all other potential sources of ignition.

“With regard to other possible sources of ignition, I have not seen sufficiently convincing evidence to confidently identify the origin of the initial fire.”

Additional reporting by PA

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