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Basic assumptions on fighting fires were rendered invalid at Grenfell

The ‘stay put’ advice to Grenfell residents at the outbreak of the fire has been under intense scrutiny at the inquiry. Jules Birch examines the context of what has been described as a series of catastrophic failures

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Grenfell fire Inquiry
Grenfell fire Inquiry
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Jules Birch examines the context of what has been described as a series of catastrophic failures that made 'stay put' advice at the Grenfell fire invalid. @jules_birch #ukhousing

Yes it was the cladding, but expert reports for the public inquiry into the Grenfell Tower fire find multiple fire safety failures in the building, its refurbishment, management, in the wider regulatory system and construction industry.

The first thing that leaps out of the report by fire engineer Dr Barbara Lane, leader of fire safety engineering at Arup, is a timeline that shows that the conditions for ‘stay put’ advice to residents had “substantially failed” by 01:26 on the morning of the fire.

“Conditions for ‘stay put’ advice to residents had “substantially failed” by 01:26 on the morning of the fire.”

This was within half an hour of the fire breaking out in Flat 16 and the London Fire Brigade did not abandon stay put until 02:47.

Those conclusions have already made some of the headlines but Dr Lane makes clear that there is a deeper context for them.

The way that high-rise buildings are designed and the way that fires in them are fought rely on the fact that multi-storey external envelope fires are not meant to happen.

But the problems went beyond just the cladding, with “multiple catastrophic fire-spread routes” increasing the likelihood that fire would spread from a flat to the cavities in the cladding system.


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So, the fire at Grenfell rendered invalid all of the basic assumptions about fighting fires from the inside and telling residents of other flats to stay inside because they will be protected by compartmentation.

“The fire at Grenfell rendered invalid all of the basic assumptions about fighting fires from the inside and telling residents of other flats to stay inside because they will be protected by compartmentation.”

That meant there had to be an improvised approach to fighting the fire from the outside on the night but most of the building was always going to out of reach even for aerial appliances – the whole reason why the risk of external fires should be designed out in the first place.

Dr Lane’s report is one of six published on the first day of the first phase of the hearings following the commemorations over the last two weeks, and all of them pose some fundamental questions about different aspects of fire safety in high-rise buildings and the regulatory regime that lies behind it.

Even before we get to questions of liability and culpability, they are yet another reminder of just how complex this inquiry is going to be.

Jules Birch, award-winning blogger

Dr Lane’s Grenfell Inquiry report in detail

Cladding and compartmentation failures

Fire safety relies on “defence in depth” or multiple levels of safety, meaning not just compartmentation but a whole range of other levels such as provision of firefighting equipment, fire doors, smoke control, ventilation of the staircase, fire alarms and active and passive fire protection systems. But once the fire spread they began to fail one by one.

As Dr Lane puts it: “The building envelope created an intolerable risk on the night of the fire, resulting in extreme harm. It did not adequately resist the spread of fire over the walls having regard to the height and use of the building. The active and passive fire protection measures within the tower were then required to mitigate an extraordinary event and, as a result, the consequences were catastrophic.”

“The building envelope created an intolerable risk on the night of the fire.”

She concludes, based on test evidence supplied to the inquiry, that the construction materials forming the rainscreen cladding system “did not comply with the recommended fire performance set out in the statutory guidance of [Approved Document] B 2013 for a building of that height”.

But the problems went beyond just the cladding, with “multiple catastrophic fire-spread routes” created by the construction form and detailing, and the arrangement of materials used around the old and new windows increasing the likelihood that fire would spread from a flat to the cavities in the cladding system.

Attempts had been made to subdivide the cavities but both the horizontal and vertical fire stopping were installed incorrectly, and “no evidence has been provided that they were ever tested for performance in an ACP [aluminium composite panels] based rainscreen cladding system of the type installed at Grenfell Tower”.

The windows did not have fire resisting cavity barriers and “these unprotected openings themselves were surrounded by combustible material”, meaning that there was a disproportionately high probability of a fire starting near a window spreading to the cladding.

The arrangement and type of construction materials in the cladding system then stretched the rest of the fire safety system to breaking point with multiple internal fires, large amounts of smoke, an early need for external firefighting and a need to change the evacuation strategy.

She finds that the cladding system was “therefore non-compliant with the functional requirement of the building regulations” but all of that had severe knock-on effects for the firefighting operation with the fire brigade never told that there was a combustible cladding system.

“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.”

In one of the most damning sections of the entire report she says: “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 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 London Fire Brigade risk assessment recorded the fire performance of the rainscreen cladding system.”

Stay put advice failure

Dr Lane says she is particularly concerned about the delay between 02:06, when a major incident was declared, and 02:47 when the advice was changed.

However, she points out that there is no requirement in the UK for automatic detection and alarm systems in high-rise buildings and no way to raise an all-out alarm in Grenfell Tower or to communicate with vulnerable residents.

As the report makes clear, Grenfell went through an extensive refurbishment between 2012 and 2016, including not just the cladding but also full internal refurbishment of the first three storeys, work on the building services on every floor and in every flat, replacement of all the fire doors and gas supply works.

The problems with the fire doors are now well known. The report says that the installed doors had different metal fittings and intumescent seals, which could have affected their performance and some were glazed and could have failed prematurely.

Dr Lane concludes that “all the flat entrance doors (from Level 4-23) were non-compliant with the fire test evidence relied on at the time of the installation” and that this non-compliance “would have contributed to the failure to prevent the spread of fire and hot smoke from the fire to the lobby.”

“There were further failures of the ventilation system that was meant to extract smoke from the lobbies and of the fire lift, with the fire brigade unable to take control.”

There were further failures of the ventilation system that was meant to extract smoke from the lobbies and of the fire lift, with the fire brigade unable to take control.

Grenfell also had a dry fire main rather than a wet one, making it non-compliant with design guidance at the time of the original construction and with current standards.

A wet main would have enabled a faster response to the original fire and enabled greater water pressure but it even they are not designed for the multiple hoses needed.

That non-compliance contributed to a failure to prevent the spread of fire and hot smoke from the flat to the lobby.

Conclusions

Overall, Dr Lane finds that “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.”

That and other issues such as the gas installation will be covered in Phase 2 of her report. In the meantime, though, she recommends action on:

  • Cladding – she says the remains concerned that some “limited combustibility” materials may not be adequate and that full scale testing should be carried out of cladding systems including windows and fixtures and fittings that would help establish whether materials need to be non-combustible in high-rise buildings.
    She adds that: “I have found no evidence so far that there was any understanding by any member of the design team or construction team, nor by the approving authority, that the rainscreen cladding system was either combustible or in breach of the building regulations.”
  • The testing and classification regime – she found “no relevant test evidence” for the cladding, fire doors not in compliance with test evidence provided and no evidence this was understood by professionals or fire safety managers.
    She adds that it is essential that there is proper understanding of test evidence and how it relates to performance. “This is a critical change which is needed throughout the design and construction industry”.
  • Standards and regulationshow to treat ‘filler material’ in cladding systems will be a crucial issue for the inquiry and potentially for future liability but Dr Lane highlights a complex and confusing array of national and European standards and guidance.

The Grenfell Tower Inquiry

The Grenfell Tower Inquiry

Closing statements

 

Day 85: victims' lawyers attack the fire brigade

 

Further expert evidence

Including some additional evidence from emergency call handlers, bereaved and relatives

 

Day 84: further evidence from survivors and relatives

Day 83: swift evacuation of tower possible if residents alerted

Day 82: initial fire was extinguished but then returned to the flat

Day 81: overheating fridge-freezer most likely cause of fire

Day 80: fire doors installed did not match product tested

Day 79: resident advised to stay put despite fire in flat

Day 78: insulation and cladding material below required standard

Day 77: molten plastic spread blaze down tower

Day 76: 'stay put' should be dropped when fire spreads across floors

 

Other witness evidence

Police, ambulance, gas suppliers, council, TMO and call room operators give evidence

 

Day 75: call room operators give evidence

Day 74: further evidence from TMO officers

Day 73: TMO boss failed to pass information to firefighters

Day 72: fire finally extinguished when gas switched off

Day 71: further questions over stay put advice

Day 70: the police evidence

 

The bereaved, survivors and relatives’ evidence

 

Day 69: video shows smoke billowing through fire door

Day 68: KCTMO removed self closing mechanism and never replaced it

Day 67: gaps in cladding fixed with duct tape

Day 66: 'don't fix broken system with a sticking plaster'

Day 65: survivor dragged disabled man down nine floors to safety

Day 64: KCTMO 'did not replace broken fire door'

Day 63: foam insulation inside cladding 'exposed' says survivor

Day 62: father gives harrowing account of son's death

Day 61: council’s management organisation slammed for faulty electrics

Day 60: stay put advice ‘led to deaths’, residents say

Day 59: residents describe problems with new windows

Day 58: survivor describes how daughter saved his life

Day 57: firefighter evidence ‘a slap in the face’, says survivor

Day 56: relations with contractor were ‘toxic’

Day 55: resident 'never happy' with stay-put advice

Day 54: tenant gives evidence about housing association

Day 53: stay put advice 'felt like trap'

Day 52: resident saved by son's phone call

 

The firefighters’ evidence

 

Day 51: firefighter feared encouraging residents to jump

Day 50: the LFB commissioner

Day 49: fire chief reveals frustration over lack of building plans

Day 48: internal fire spread 'bigger story' than cladding

Day 47: fire officer considered evacuating crews over building collapse fears

Day 46: 'we were improvising' senior firefighter admits

Day 45: firefighter urged for abandonment of 'stay put' policy

Day 44: firefighter recalls radio signal difficulties

Day 43: call hander 'uncomfortable' with insisting residents stay put

Day 42: residents only told to leave if they called fire brigade back

Day 41: breathing equipment delay 'hampered rescues on upper floors'

Day 40: chiefs told firefighters to abandon policy

Day 39: firefighters reveal dramatic rescue of children

Day 38: firefighters issue aplogies to families

Day 37: council 'unable to provide tower plans'

Day 36: QC defends inquiry process

Day 35: Javid would welcome interim recommendations

Day 34: water from hose 'too weak' to reach the flames

Day 33: 'oh my god, we've been telling people to stay put'

Day 32: further fire fighter describes lack of equipment and low water pressure

Day 31: 'incredibly difficult' task of recording information outlined

Day 30: struggle to maintain control over rescue operation described

Day 29: fire service 'overwhelmed' by survival guidance calls

Day 28: 'the building beat us'

Day 27: firefighters 'forced to abandon plans to reach roof'

Day 26: poor signage hindered rescue efforts

Day 25: water pressure left firefighting equipment 'like garden hose'

Day 24: decision to abandon 'stay put' explored

Day 23: TV images 'could have assissted' rescue effort

Day 22: description of hectic scenes in the control centre

Day 21: account from the fire service 'nerve centre'

Day 20: firefighter describes 'huge volume' of calls from trapped residents

Day 19: firefighter 'given no training on cladding fires'

Day 18: evacuation would have been 'huge catastrophe'

Day 17: firefighters describe access and lift issues

Day 16: scenes of carnage likened to 9/11

Day 15: firefighters recount trauma of survival guidance calls

Day 14: firefighters describe spread of blaze

Day 13: firefighters recall radio difficulties

Day 12: "it was like a war zone"

Day 11: questions raised over fire fighters' radios

Day 10: watch manager emotional under questioning

Day nine: lead firefighter 'not trained in stay put policy'

 

The expert reports: authors give evidence to inquiry

 

Day eight: where the fire started

Day seven: what was in the cladding?

Day six: the cause and spread of the fire

Day five: expert highlights key issues

Day four: firefighters defend response to fire

Day three: council and contractors appear for the first time

Day two: lawyers for the survivors make their case

Day one: expert evidence released on cladding and stay put

 

The commemoration hearings

 

30 May: Grenfell Council 'recognised it should not house disabled victim above four storeys'

29 May: Anger on day six of the Grenfell Inquiry

25 May: Grenfell families 'forced to live in chimney with stay put policy'

24 May: Grenfell family complained about father being housed on 17th floor

23 May: Tributes to children on third day of Grenfell hearings

22 May: Emotions run high as Grenfell bereaved shown footage of the tower burning

21 May: Grenfell victims share tributes as inquiry opens

 

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