Last week, Sir Martin Moore-Bick released his long awaited report into the Grenfell Tower fire of 14 June 2017, in which 72 people died. The fire was the worst health and safety related disaster this century.
The report marked the end of the Inquiry's first phase, which looked at the cause of the fire, its rapid spread, the response of London Fire Brigade, and other emergency services.
Note that some of what follows may be upsetting.
The report, which as you can imagine, makes harrowing reading, follows evidence given by survivors, the emergency services, and others, as well as records of telephone calls on that fateful night.
The fire started with a faulty fridge-freezer on the 4th floor. The occupier of the flat is not blamed in the report. The fire spread rapidly to the building's exterior, and across the four faces of the building via an aluminium composite rain screen, fitted in 2016, which contained polyethylene cores. These fuelled the fire. Apartment windows had been relocated during the 2016 refurbishment to make them flush with cladding, without installing a non-combustible layer. This compromised the building's fire compartmentation system, designed to prevent fire spread.
While praising the firefighters who risked their lives that night in unprecedented conditions (thermal imaging cameras carried by the firefighters showed temperatures in some parts of the building in excess of 1000C), the report severely criticises the fire brigades management for "gravely inadequate" planning and preparation.
The report states that “There were serious deficiencies in command and control, although additional resources arrived swiftly, some senior officers failed to give sufficient practical support or inform themselves quickly enough of conditions and operations within the building.” Communication was poor, and, crucially, the decision to evacuate, rather than stay put (the nationally agreed policy for fires in high rise buildings) was taken far too late (and not communicated sufficiently).
The report makes many recommendations, which I believe should be acted on quickly.
These include new legal obligations on owners and managers of high-rise residential buildings:
to inform the local fire service about and design of external walls and changes to them,
to draw up-to-date fire and emergency plans,
to test monthly firefighting lifts and report the results to the fire service,
to ensure all residents understand the evacuation procedures,
to conduct three monthly checks on all fire doors to ensure the self-closing mechanisms work correctly.
The report details what is known to have happened in the tower minute by minute from the fire starting at just before 1am, to when the last person was brought out alive just after 8am.
There were many heroes that night, not least the individual fire fighters, and 999 call handlers who received calls from trapped and panicking residents. Some residents even saved others at their own expense.
In one example, a man on the top floor helped four others onto the stairs to escape. They thought he was following. Three minutes later, at 2.40am he left a voicemail with his brother in law... “Goodbye. We are now leaving this world, goodbye. I hope I haven’t disappointed you. Goodbye to all.” At 2.41am, the body of Mohammed 'Saber' Neda was found in the children’s playground on the west side of the tower. He had jumped from the tower after leaving the voicemail message. The four people he helped to the staircase safely left the tower at 2.42am.
This is just one example of many in the report that night.
I have always been an advocate of the stay put strategy in high rise tower blocks. When compartmentalisation is in place, this is often the safest thing to do. It keeps staircases clear for those who do need to escape. However, the lack of a change of decision on the night of 14 June that year clearly led to people losing their lives. The decision was made far too late, due to poor planning, poor systems and poor communications.
A BT operator talking to a trapped resident on one of the upper floors that night heard the resident say "We could have left a long time ago, we could have but they said stay in the flat, stay in the flat. We stayed in the flat. We didn't leave." Abdulaziz El Wahabi and his family died soon after.
Evacuating a floor at a time I believe to still be a good policy, particularly in office blocks. But when it was very clear that compartmentalisation had failed, the decision should have been made much earlier to change the advice given to trapped residents to leave immediately.
Whoever is elected in the forthcoming General Election must take notice of this report, and the outcome of the next phase which will look more at the building management itself.
Seventy-two innocent people lost their lives unnecessarily on that day in June 2017. Many more had their lives changed forever. This should never ever happen again.
We must learn.
And we must act.