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Six key failures in the way Grenfell Tower was managed before the fire

Insight07.09.2110.30 AM by Peter Apps

As the inquiry prepares to resume, Peter Apps recaps some of what we have learned about the actions of the Royal Borough of Kensington and Chelsea (RBKC) and Kensington and Chelsea Tenant Management Organisation (KCTMO) in the years before the fire

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As the inquiry prepares to resume, @PeteApps recaps some of what we have learned about the actions of the Royal Borough of Kensington and Chelsea (RBKC) and Kensington and Chelsea Tenant Management Organisation (KCTMO) in the years before the fire

1. No evacuation plans were made for residents with disabilities

At the start of this module, the fire was described by a barrister acting for the bereaved as “a landmark act of discrimination against the disabled and vulnerable”.

It has not been difficult to see why: 15 of the 72 victims were disabled, meaning the fire killed 40% of the disabled residents present on the night.

It has emerged that none of them had ‘personal emergency evacuation plans’ (PEEPs) making preparations for their escape from the fire.

Emails disclosed so far show that KCTMO did consider making these plans after consultancy Salvus specifically recommended “formal procedures to deal effectively with fire safety issues associated with disabled or vulnerable tenants and leaseholders” in a review of the organisation’s strategies in 2009.

But over the next few years, this simply dwindled away. In fire risk assessments in 2012, 2014 and twice in 2016, assessor Carl Stokes ticked a box saying the building was adequately equipped for the escape of disabled residents, and wrote (with some minor variations): “At the time of the assessment there was no evidence of any resident within the premises who suffers from a sensory impairment which would prevent them from hearing a shouted warning of fire.”

He justified this in evidence by saying that he believed if there was evidence of disabled people in the building it was up to KCTMO to tell him. In total, in more than six years as risk assessor he prepared only two PEEPs for all 650 blocks of flats the council owned.

Staff at KCTMO told the inquiry they believed the ‘stay put’ policy was adequate protection and argued that it would have been impossible to provide a ‘PEEP’ without staff on site. Many struggled to answer what they believed would happen to disabled people if the fire was within their own flat.

The organisation did gather data on residents with disabilities in 2014 – but it was never used to prepare PEEPs and was held across two separate databases.

The inquiry has also heard that government guidance described the provision of PEEPs for disabled residents of blocks of flats as “usually unnecessary”. This approach was adopted by many social landlords, including RBKC and KCTMO, despite its contradiction with other legal obligations and guidance.

Colin Todd (pictured above), director of the consultancy that produced this guide for government, argued that providing PEEPs in general needs housing was not “practicable” when he gave evidence as an expert.

2. The fire risk assessor ‘invented’ some of his qualifications, and copied and pasted from other assessments

Mr Stokes’ (pictured above) cross-examination has been one of the longest of this module. A former firefighter, he had set up as a sole trader carrying out risk assessments shortly before taking on the contract to assess all 650 blocks owned by RBKC.

Among many other issues, he was asked why he included a series of ‘post-nominals’ after his name on his CV which did not reflect his actual qualifications.

Lawyers for the survivors have accused him of effectively “inventing” his qualifications by doing this. Mr Stokes said he did not know how post-nominals worked and had intended to refer to training courses he attended.

His risk assessments of the tower have also been criticised – particularly for using wording that was copied and pasted from the assessment of other buildings. This included notes on the safety of pigeon netting and balconies at Grenfell. The tower had neither.

He also faced tough questions over an email sent in 2012 when he urged KCTMO to “say you have nobody” when the London Fire Brigade (LFB) asked for details of disabled people in high rises, for inclusion in a sprinkler pilot.

“If you identify anybody now, questions like why were they not included in the building’s [fire risk Assessment] spring to mind. A good response I believe would be thank you for this information, if we find anyone in the future we will let you know,” he wrote.

He denied that he was encouraging the organisation to lie, and said that he felt the request was specifically seeking details of heavy smokers with other vulnerabilities, and that he genuinely believed there were none.

He also told KCTMO that the cladding used on the tower complied with building regulations, after the LFB issued a general warning about combustible facades in 2017.

He gave this assurance despite accepting in his witness statement that his knowledge of cladding was “limited” and that he was “not a construction or materials specialist”.

3. Hundreds of important actions identified in fire risk assessments went uncompleted

Mr Stokes’ risk assessments identified thousands of specific actions to take to make buildings safe, from the complex to the mundane. But KCTMO struggled to get them done.

Board papers record that by March 2014 there was an astonishing backlog of 1,400 actions outstanding and incomplete.

Board meeting notes list KCTMO electing not to disclose this backlog to the LFB – as doing so would “result in more scrutiny from the LFB and also possible enforcement action”.

KCTMO witnesses linked this to the poor performance of repairs contractors (one had recently gone bust, and the replacement contractor was struggling) as well as the complexity of completing some larger actions.

Over the next few years an effort was made to address the backlog, but it was never completed. At the time of the fire there were still 287 actions outstanding – 128 of them more than a year old.

There were also questions as to whether KCTMO had sought to interfere in the process of raising actions.

Peter Maddison (pictured above), for example, asked for some required actions to be recategorised as ‘best practice’ rather than ‘absolute requirements’. He denied this was an effort to interfere, saying he was simply seeking clarity over the required works.

4. Defective fire doors were not fixed – despite the warning of another fire

Missing and broken self-closing devices on flat entrance doors were a major cause of the rapid spread of smoke through the lobbies and staircase at Grenfell Tower.

As residents fled, doors did not swing shut behind them – meaning smoke was able to billow out, fill up the communal areas and trap those who had not yet escaped.

The inquiry has revealed that RBKC and KCTMO were very specifically warned about this risk by the LFB but did not act in time.

In October 2015, Adair Tower (another block about a mile away from Grenfell) had to be evacuated because of fire and smoke spreading internally. The LFB had actually issued a deficiency notice a few weeks before this blaze, after discovering missing self-closers.

Following the fire, the brigade upgraded this to an enforcement notice, meaning KCTMO was legally obliged to complete the work within a set time period.

But the LFB also wanted checks throughout the rest of the stock, and repairs to any missing or broken self-closers. RBKC resisted this. Laura Johnson (pictured above), director of housing at the council, complained internally that the LFB was “unaccountable” and “hard if not impossible to challenge”.

The cost of retrofitting self-closers was estimated at £620,000 and there would be an ongoing cost of around £200,000 a year associated with monitoring.

Internal minutes record that Ms Johnson had “said no” to this work (she claimed when questioned that she had simply requested clarification of the exact work required). The replacement work was eventually pushed over five years.

KCTMO minutes from March 2017 described an inspection programme as “a huge cost” and said “nobody [else in the social housing sector] has an inspection process at present”. It was not introduced.

What was missed was an extremely serious position at Grenfell Tower. New doors fitted in 2011 had a specific problem with self-closers: the bolts holding the devices in were too small and would pull out due to the weight of the door. A caretaker (now deceased) admitted to removing many of them as the only way he could find to correct the fault.

Several residents note complaints to KCTMO about this specific issue. Edward Daffarn, for example, raised the issue of a jammed closing device on Flat 136 but was told it could simply be pulled to with force. The device was in fact broken, and the flat was the first on his floor to be affected by the fire.

A specific deficiency notice raising the issue of self-closers at Grenfell Tower was also issued in November 2016.

Post-fire inspections have revealed that as many as two-thirds of the flat entrance doors in the tower had broken self-closers.

5. Serious complaints about fire safety went unaddressed

Residents made numerous complaints about fire safety, dating as far back as 2010 when a prior fire in the tower caused smoke to spread across several floors, with three residents injured due to smoke inhalation.

“Should a fire occur in the staircase of Grenfell Tower, there will be no escape route for residents,” wrote Shah Ahmed, chair of the leaseholders association, whose wife was injured in the fire. He received a two-sentence response.

Complaints increased in velocity as the refurbishment started – and many of these were tied to safety concerns. Some were posted on the Grenfell Action Group blog, which was written by Mr Daffarn (pictured above) and his neighbour Francis O’Connor.

But this blog (which was occasionally strongly worded) was blocked on KCTMO’s servers. It would go on to warn specifically of a “catastrophic incident” at the tower.

Mr Daffarn and others also attempted to form collective groups to complain about various issues – not least the placement of heating interface units next to their front doors.

Residents complained that contractors would wait until vulnerable family members were home alone so they could pressure them to be let in. There were also accusations of bullying and threats that hot water would be removed if access was not granted (which Rydon witnesses have firmly denied).

They attempted to form a group – Grenfell Community Unite – to speak with a united voice against the refurbishment. But KCTMO refused to recognise them initially and it was only when a local MP intervened that they were granted a meeting.

But while they were able to secure a U-turn on the positioning of the new heating units, they were knocked back in their consistent call for an independent review of the safety of the refurbishment. These calls were still being made just weeks before the fire.

6. The smoke ventilation system was left unrepaired for six years and there are question marks about the replacement system

One specific issue residents complained about was the smoke ventilation system. The 2010 fire revealed that this system was not working properly – allowing smoke to leak out of vents on upper floors instead of funnelling it out of the building.

This issue went unrepaired for six years as KCTMO elected to have upgrade work completed alongside the wider refurbishment, despite the LFB issuing a deficiency notice in March 2014, which offered a six-week deadline to complete the work.

It also refused Mr Daffarn’s Freedom of Information request for minutes that would have exposed this defect at around the same time, with an internal email saying it would cause him to “to raise more queries on his blog”.

After hearing that the crucial work would be delayed again in December 2014, Janice Wray (pictured above), head of health and safety at KCTMO, wrote in an internal email: “Let’s hope our luck holds and there are no fires in the meantime.”

When the system was replaced it was fitted with a new, bespoke system that did not comply with guidance. Contractors involved in this work said this was done because the design of the tower made other options impossible.

The inquiry continues.

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