Fire chiefs were castigated in Sir Martin Moore-Bick’s 935-page report into the devastating blaze.
The London Fire Brigade was plagued with ‘institutional failures’ and its preparation for a Grenfell-style inferno was ‘gravely inadequate’, the retired judge found in 2019.
But he also ruled the tower’s cladding panels broke building regulations and actively helped spread the blaze. Among his findings:
How the blaze started
The Grenfell tragedy started with an electrical fault in the fridge-freezer of Flat 16, occupied by Behailu Kebede, pictured here leaving his flat on the day of the fire. The report said that Kebede was not responsible for what followed
The Grenfell tragedy started with an electrical fault in the fridge-freezer of Flat 16, but its occupant Behailu Kebede was not to blame, the report says.
Sir Martin said it was more important to establish ‘how the failure of a common domestic appliance could have such disastrous consequences’.
‘Inadequate’ fire planning
The firefighters who repeatedly ran into the burning building were praised for their ‘extraordinary bravery and selfless devotion to duty’.
But they were let down by having no training for a fire of such magnitude.
Sir Martin said: ‘The London Fire Brigade’s preparation and planning for a fire such as that at Grenfell Tower was gravely inadequate.’ Officers were faced ‘with a situation for which they had not properly been prepared’, and commanders had ‘no training’ on the dangers associated with combustible cladding.
Nor did they have any training on how to recognise the need for an evacuation of a high-rise block – let alone mount one. Sir Martin said there was simply ‘no contingency plan’ for evacuation.
The fire service’s database on large London buildings was ‘many years out of date’ and contained ‘almost no information of use’.
Safety design flaws
Firefighters spray water onto the Grenfell Tower block which was destroyed in a disastrous fire, in north Kensington, West London, Britain June 16, 2017
This picture of the Grenfell Tower six months after the blaze shows the damage to the external building
There was a catastrophic failure of ‘compartmentation’ – the safety design that supposedly stops fires spreading from flat to flat.
Had compartmentation worked, it would have contained the blaze in the first flat until firefighters could put it out, enabling occupants elsewhere to ‘stay put’.
The ‘rapid’ failure of compartmentation meant the intensity of the heat shattered glass windows. Kitchen extractor fans were deformed and dislodged, giving the flames a deadly pathway. Fire doors at the front of flats failed in their job, filling lobbies with smoke.
Lives were probably lost because crews and 999 operators wasted ‘the best part of an hour’ telling the block’s occupants to ‘stay put’ in their flats – before realising the blaze was wildly out of control, the report said.
Incident commanders failed to recognise that compartmentation had failed and a full evacuation may have been necessary. They never gained control.
Sir Martin said of the stay-put strategy: ‘Once it was clear that the fire was out of control and that compartmentation had failed, a decision should have been taken to organise the evacuation.
That decision should have been made between 1.30am and 1.50am and would be likely to have resulted in fewer fatalities.’
He said ‘the best part of an hour was lost’ before the stay-put advice was revoked at 2.47am.
Pictured are the ashened lifts inside the Grenfell tower
Many physical and electronic communication systems did not work properly on the night of the fire. Information sharing between the control room and the commanders on the ground was ‘improvised, uncertain and prone to error’.
Crucial information about the spread and extent of the fire was not shared by senior officers at the scene – and they were not kept abreast of vital information that was coming in to the 999 centre from stricken residents.
Control room staff swamped by 999 calls
Control room operators were in the ‘invidious’ position of being outnumbered by an unprecedented number of 999 calls on the night and ‘responded with great courage and dedication in the most harrowing of circumstances’, said Sir Martin.
Emotional Kensington firemen join bereaved family members including the parents and sister of Jessica Urbano, at the tribute wall near to Grenfell Tower in West London for a minutes’ silence
Control room staff ‘undoubtedly saved lives’, but their operation was beset by ‘shortcomings in practice, policy and training’. Call handlers did not always obtain necessary details from those inside Grenfell, such as their flat numbers. Others did not know when to tell residents to evacuate.
Mistakes at a similar blaze were repeated
Damningly, the report says lessons had not been learnt from the Lakanal House fire of 2009. Three women and three children died in that high-rise blaze in Camberwell, South London which bore many similar traits.
Sir Martin said: ‘Mistakes made in responding to the Lakanal House fire were repeated.’
He said 999 operators were ‘not aware of the danger of assuming that crews would always reach callers’.
Outgoing fire chief Dany Cotton was criticised for her evidence to the inquiry in September last year
The tower’s outside walls failed to comply with building regulations. There was ‘compelling evidence’ that the walls did not ‘adequately resist the spread of fire – on the contrary, they actively promoted it.’
Outgoing fire chief Dany Cotton was criticised for her evidence to the inquiry in September last year. Sir Martin suggested her attitude meant the brigade was at risk of failing to learn the lessons from Grenfell.
He also highlighted her apparent lack of curiosity on arriving at the scene when told the stay-put advice had been abandoned.
Sir Martin wrote: ‘Quite apart from its remarkable insensitivity to the families of the deceased and to those who escaped from their burning homes with their lives, the Commissioner’s evidence that she would not change anything about the response, even with hindsight, only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the fire.’