Flawed leadership at the top of the London Fire Brigade, delays in ordering an evacuation and the flammable cladding used to wrap the building in, were all strongly criticised in a damning report from the Grenfell Tower public inquiry.

The lengthy report sets out what happened on the night of 14 June 2017 when 72 people died in a fire that consumed the 24-storey tower block. It was the country’s biggest loss of life since the Hillsborough Stadium disaster in 1989 and came just eight years after a similar fire at Lakanal House in South East London, from which the warning signs were not acted upon.

The first phase report was initially expected to be published about 18 months ago. Survivors and relatives of the victims voiced their support for the unexpectedly hard-hitting tone of Sir Martin Moore-Bick’s report, but also expressed their frustration at the limited criticism of the tower block’s owners and managers.

Sir Martin has made 46 wide-ranging recommendations in his report to ensure the future safety of high-rise residents and the Prime Minister has already said the Government accepts all of them. Sir Martin also signposted areas he will investigate further in phase two, such as the merits of water sprinklers.

The second phase of the inquiry is due to start in January next year and it will focus on the wider circumstances of the fire, including the design of the building and its refurbishment in 2014-16. However, Sir Martin has already concluded that the external walls of the building failed to comply with the relevant building regulations “in that they did not adequately resist the spread of fire..…. on the contrary, they actively promoted it.”

Flawed response
The report was particularly critical of the LFB’s lack of preparation and planning for such a large-scale fire and the inadequate training given to its frontline staff (firefighters, 999 control room staff and incident commanders), as well as deficiencies in its equipment, procedures and communications.

In particular the report highlighted that the Fire Brigade lacked relevant and accurate information about the tower block and its various attributes, as well as details of the refurbishment. The LFB’s communications systems and liaison protocols and equipment were considered inadequate. The emergency services collectively struggled with the enormity of the tragedy.

Sir Martin was very critical of the LFB’s commissioner Dany Cotton for her apparent insensitivity towards the victims when giving her evidence to the inquiry and for the brigade’s significant systemic failings. Ms Cotton is due to retire next year and has resisted calls for her to resign. She also challenged Sir Martin’s conclusion that an earlier evacuation of the building could have saved many lives.

Matt Wrack, the general secretary of the Fire Brigades Union said the running order for the inquiry was the wrong way around and the causes of the fire should have been examined first. Many survivors of the Grenfell fire also spoke movingly in support of frontline firefighters, who they said put their own lives at risk to help the tower’s residents.

Widespread problems
When the House of Commons held an emergency debate on the day the inquiry report was published, the local Kensington MP Emma Dent Coad named a series of politicians and company bosses involved in the refurbishment project, who she said were directly responsible for a variety of contributory factors to the disaster.

Other MPs contributing to the debate spoke critically about the stay put policy, the failure to learn lessons from the Lakanal House fire and the large number of residential buildings still covered in various types of flammable cladding. They said not enough money was being made available to make all residential tower blocks safe in the social and private sectors. This was leaving tens of thousands exposed to huge risks and stuck in a financial limbo.

The Housing Secretary Robert Jenrick urged all building owners to act now (before they were named and shamed) and not to wait for legislation. He also said finances would be made available for the report’s recommendations to be implemented in full and that policies like ‘stay put’ and the retrofitting of sprinklers would be thoroughly reviewed. He confirmed that nine households made homeless by the Grenfell fire were still awaiting permanent rehousing.

John Healey, the Shadow Housing Secretary highlighted that Dame Judith Hackitt reported on fire safety and construction issues some 18 months ago but still no legislation was in place, and that Grenfell Tower residents had been raising safety concerns in the months before the fire but they had been ignored.

Hard hitting
According to the report, a catastrophic failure of ‘compartmentation’ meant the fire and smoke spread rapidly up and around the building. Many fire stops were either missing, incomplete or mispositioned, while some fire doors failed and others had been propped open.

This rendered the ‘stay put’ policy unviable. But by the time an evacuation was ordered, the tower’s single staircase was filled with impenetrable smoke. “Fewer people would have died if the order to evacuate had been given by 02.00,” said Sir Martin.

Among the many issues highlighted in the inquiry’s report were:

• A lack of training in how to “recognise the need for an evacuation or how to organise one”;
• Incident commanders “of relatively junior rank” being unable to change strategy;
• Control room officers lacked training on when to advise callers to evacuate;
• An assumption that crews would reach callers, resulting in “assurances which were not well founded”;
• Communication between the control room and those on the ground being “improvised, uncertain and prone to error”; and
• A lack of an organised way to share information within the control room, meaning officers had “no overall picture of the speed or pattern of fire spread”.

Legislation promised
Sir Martin said the principal reason the fire spread so quickly “up, down and around the building was the presence of the aluminium composite material (ACM) rainscreen panels with polyethylene cores, which acted as a source of fuel for the growing fire”.

He said the rapid spread of the fire across the tower was “profoundly shocking” and he ruled the refurbishment breached building regulations. This will increase the pressure on the companies involved in the works ahead of the inquiry’s second phase.

When he opened the Commons debate, the Prime Minister told MPs “I can confirm that where Sir Martin recommends responsibility for fire safety be taken on by central government, we will legislate accordingly. We plan to accept in principle all of the recommendations that Sir Martin makes.”

Watched by relatives, survivors and campaigners from the public gallery, Boris Johnson said he would “not allow the lessons of this tragedy to fall through the cracks”. Paying tribute to the Grenfell community, he added: “To them I say once again that the truth will out and justice will be done, and that Grenfell Tower and the people who called it home will never be forgotten.”

But there remains frustration among the Grenfell community that this first part of the inquiry did not focus more on those who made the cladding and oversaw the refurbishment of the tower. That will only happen in the second phase of the inquiry next year and then the survivors have got even longer to wait for the Metropolitan Police investigation to finish.

By Patrick Mooney, Editor