Serious fire safety breaches at Grenfell Tower included more than 100 non-compliant fire doors, a firefighting lift that did not work and a “stay put” policy that failed, the inquiry into the disaster has been told.
A report by Dr Barbara Lane, a leading fire safety engineer who was commissioned by the inquiry to investigate fire protection measures and the spread of flames and smoke, concluded there was “a culture of non-compliance” at the tower.
Her report amounted to a litany of failings including the revelation that the pipe system to get water up the 24-storey block to fight the fire could not cope and was overloaded, leaving the upper floors, where most people died, vulnerable.
Fire doors to flats, which should have resisted fire for 60 minutes, only lasted as little as 20 minutes and their closers did not work in some cases.
The cladding system was “substantially to blame for the tragedy” and produced toxic smoke that slowed the firefighters because they had to wear breathing apparatus and “the ultimate consequence was a disproportionately high loss of life”, she said.
Fifteen people living on the 18th to 22nd floors went up to the 23rd floor, she found, and 47 of those who died were found on level 18 and above. No one died from any of the flats on level 10 or below.
“It would appear that people moved upwards because of the spread of smoke and fire,” she said.
Her interim conclusions were among five expert reports released on the eighth day of the inquiry – and the first to hear detailed expert evidence.
Lane said: “There was a total failing of the principle of stay put,” the strategy that resulted in residents being told to remain in their flats. She said this had become ineffective by 1.26am. Yet the policy remained in place for another hour and seven minutes.
A major incident was declared at 2:06am and yet the stay put strategy remained in place until 2:47am, by which time the lobbies were filled with thick and “boiling hot” smoke allowing very low and sometimes zero visibility.
She said there needed to be “serious and urgent” consideration to changing the current approach in buildings enveloped in similar material to Grenfell.
“I am particularly concerned by the delay from 2.06am, when a major incident was declared, to 2.47am,” she said.
The firefighting lift did not work because the firefighting “switch” function – a kind of override allowing firefighters to use the lift – failed.
The failure of the fire lift system delayed firefighters getting to the flat where the fire started. “This might have increased the chances of extinguishing the fire before it spread externally,” she said.
Its failure also prevented the firefighters getting equipment higher up the building.
“All operations by the fire service within the 23 storeys were therefore required to be by means of walking up and down the stair only.”
The building had a system for removing smoke from the lobbies, but this was a “bespoke” design and was not compliant with building regulations, she said. It did not operate as intended, and attempts by firefighters to take control of it failed.
Lane was damning about the cladding, which she said was “non-compliant with the functional requirement of the building regulations”.
She said: “I have found no evidence yet that any member of the design team or the construction 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 would perform in a fire.
“Further, I have found no evidence that the [tenant management organisation] risk assessment recorded the fire performance of the rainscreen cladding system, nor have I found evidence that the LFB [London fire brigade] risk assessment recorded the fire performance of the rainscreen cladding.”
She found that all of the fire doors between the fourth and 24th floors were “not compliant with fire test evidence relied upon at the time of installation”, and that this would have contributed to the spread of smoke and fire into the lobbies.
The doors allowed smoke and flames to spread between the doors and the door frames, multiple untested components in the doors allowed fire cross them and an unknown number of self-closers failed.
Some fire doors were also held open by the firefighters’ hoses rising up the building and, in one case, a dead body.
The heat in the lobbies would have caused “immediate pain” to exposed skin and the “thick black smoke” in the lobbies would put people off from trying to leave and prevent firefighters from being able to use lobbies as a bridgehead or search base.”
It also emerged that no fullscale fire tests of cladding systems using the aluminium composite material panels fixed to Grenfell and more than 300 other towers across England were ever carried out before the fire.
Colin Todd, a fire engineer commissioned by the inquiry, said no BS8414 tests were carried out using the material before the blaze. Subsequent tests have shown the material often fails to meet building regulations and it is being urgently stripped from hundreds of towers at a cost estimated to be in excess of £1bn.
A separate report examining the start of the blaze by Prof Niamh Nic Daéid, the director of the Leverhulme Research Centre for Forensic Science at Dundee University, said the fire was thought to have originated in or near the fridge freezer in flat 16 on the fourth floor.
Her provisional report, dated March 2018, contained details of the first call, which was made by Behailu Kebede, who lived in flat 16 with two others, to London Fire Brigade just before 1am.
“Mr Bahailu Kebede states in his witness statement that he was wakened at around 00.55 by the sound of a smoke alarm, which he believed was in the kitchen of his flat (flat 16 on the fourth floor of Grenfell Tower).
“He went into the kitchen and saw smoke in the area of the fridge/freezer and the kitchen window. He woke the other occupants of the flat and phoned the fire brigade using his mobile phone and alerted the other residents living in the various flats on floor 4 of Grenfell Tower.”
The London fire brigade sent four fire engines in their initial response to Kebede’s call. The first two firefighters to enter the flat broke down the door and described how “black smoke billowed out”. They checked the bedrooms and opened a door that led to the living room and noted there was was “no sign of fire”, the report states.
The fire appeared to be in the top left corner of the kitchen. It was described by one as “an isolated curtain of flame from about 2-3ft in the air to the ceiling”.
Images captured by their thermal imaging camera suggest the hot fire gases and flames had spread across the window space by the time the firefighters had opened the kitchen door for the first time.
Increased temperatures were indicated above the tall fridge freezer and to the immediate lefthand side, where the window was located. The thermal images also recorded what looks like falling embers outside the window. The images appear to show that the fire may have breached through the sliding doors between the kitchen and living room.
A second fire crew searched the bedrooms, bathroom and living room before taking over the firefighting activities in the kitchen.
The report said that one firefighter at the scene, John O’Hanlon, described the fridge, saying: “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 flame was around 30cm high.
“The window had gone by then, broken … that’s when we noticed the window had completely gone. Even the frame wasn’t there and we noticed that it was on fire, that the window surround was on fire.
“We walked over to the window and started spraying the window frame. It didn’t have any effect on it, at which point I sat on the windowsill and was leaning out and trying to hit what I thought was the window surround.”