Grenfell Tower Inquiry

Grenfell Tower Inquiry

Date	14 September 2017 (2017-09-14) - (in progress)
Location	Holborn, London, United Kingdom
Participants	Sir Martin Moore-Bick (chairman)
Website	www.grenfelltowerinquiry.org.uk

The Grenfell Tower Inquiry is a British public inquiry into the Grenfell Tower fire, which killed 72 people and destroyed Grenfell Tower on 14 June 2017. It was ordered by Prime Minister Theresa May on the following day. May announced on 29 June 2017 that the inquiry would be chaired by retired judge Sir Martin Moore-Bick, with the immediate priority "to establish the facts of what happened at Grenfell Tower in order to take the necessary action to prevent a similar tragedy from happening again." She promised that "No stone will be left unturned by this inquiry."

On 15 August 2017, the terms of reference of the Inquiry were announced. The first hearing opened on 14 September 2017.

Background

Main articles: Grenfell Tower and Grenfell Tower fire

Map of the western side of the Lancaster West Estate

Grenfell Tower was a 24-storey residential tower block in North Kensington, London, England. It was completed in 1974, as part of the first phase of the Lancaster West Estate.

The concrete structure's top 20 storeys consisted of 120 flats, with a total of 200 bedrooms. Its first four storeys were nonresidential until its most recent refurbishment in 2015–2016, which converted two of them to residential use, bringing it up to 127 flats and 227 bedrooms. It also received new plastic framed windows and new cladding with thermal insulation.

A major fire seriously damaged the building on 14 June 2017, causing 72 deaths of the 293 people who were believed to be in the 129-flat tower that night. The inquiry is to determine the causes and recommend changes to minimise the risk of a similar event occurring ever again. A previous catastrophe at the Ronan Point tower block in 1968 also generated an inquiry.

Announcement of the Inquiry

Theresa May, the prime minister made a statement to Parliament on 22 June announced a judge led inquiry, saying "No stone will be left unturned by this Inquiry". The chosen judge was Sir Martin Moore-Bick, and when she announced his name on 29 June she stated that "Before the Inquiry starts Sir Martin will consult all those with an interest, including survivors and victims’ families, about the terms of reference."

Preparation

138-142 Holborn, where the inquiry is being held.

The inquiry was announced on 22 June, and the judge Sir Martin Moore-Bick named on 29th June, he met with residents the same day. Also on 29 June, after Moore-Bick had met some survivors of the tragedy at the site of the fire in North Kensington that day, he said that he was "doubtful" that the process would be as wide-ranging as some residents hoped and that the inquiry could be limited to the cause, how the fire spread, and the prevention of future fires.

On 30 June, Labour Party leader Jeremy Corbyn wrote to Theresa May to say that the inquiry's terms should be broad, because the fire had "much wider implications for national policy issues". Former Lord Chancellor Lord Falconer said that "The inquiry has got to look at how [the regulatory] regime developed, or I think the residents would feel they were let down."

On 5 July, the Inquiry team invited "all those affected by the Grenfell Tower fire and others with an interest" "to help shape the work of the public Inquiry". It issued a consultation document which stated that the Inquiry will need to examine "circumstances well beyond the design, construction and modification of the building itself", including "the role of relevant public authorities and contractors", "the adequacy and enforcement of relevant regulations", "the arrangements in place locally for handling emergencies of this sort," and "the handling of concerns previously expressed by local residents." The deadline for consultation on the terms of reference had initially been 14 July, but was extended (on 11 July) to 28 July.

On 17 July, Corbyn wrote again to Theresa May, saying: "As I set out in my letter dated 30 June, there is considerable concern among residents and others that the judge leading the inquiry has already been directed towards a narrowly defined Terms of Reference, which will not bring residents the answers they seek."

"Following feedback from local residents and survivors", on 19 July, Moore-Bick further extended the terms of reference consultation period to 4 August.

Official terms of reference

On 15 August 2017 Theresa May announced the terms of reference, being to examine "the circumstances surrounding the fire", including:

(a) the immediate cause or causes of the fire and how it spread to the whole building;

(b) the building's design and construction, and "decisions relating to its modification, refurbishment and management";

(c) "the scope and adequacy of building regulations, fire regulations and other legislation, guidance and industry practice" relevant to the "design, construction, equipping and management" of high-rise blocks of flats;

(d) whether such regulations and so on were complied with, and related fire safety measures adopted;

(e) the arrangements made by the local council and other organisations with responsibility for Grenfell Tower for receiving and using (or otherwise) information obtained both from local residents and which was available elsewhere (including anything derived from fires in other buildings) relating to the risk of fire risks at the tower, and action taken in response;

(f) the fire prevention and safety measures in place at the Tower on 14 June 2017;

(g) the response of the Fire Brigade;

(h) the response of both the Government and the local council in the days immediately following the fire.

Finally, to respond to the Prime Minister as soon as possible, with recommendations.

Proceedings

The inquiry opened on 14 September 2017. Procedural hearings were held in December 2017 and March 2018.

Campaigners argued that the inquiry should include an advisory panel to assist Moore-Bick. In May 2018, it was announced that two panelists would sit alongside Moore-Bick for the second stage of the inquiry.

In May 2018, a series of commemorative hearings were held in which relatives and survivors paid tribute to the 72 who had died.

Phase 1 evidence

Evidential hearings began on 4 June 2018. The first week saw opening statements on behalf of the key organizations and the presentation of reports by key expert witnesses. No hearings were held in the week beginning on 11 June 2018, as the anniversary of the fire and commemorations fell within this week. The hearings resumed on 18 June 2018.

The appointed expert witnesses are:

• Dr Barbara Lane, a fire safety engineer from Arup
• Colin Todd, a fire safety consultant from CS Todd & Associates Ltd
• Professor David Purser, from Hartford Environmental Research
• Professor Edwin Galea, Professor of Mathematical Modelling at the University of Greenwich
• Dr Ivan Stoianov, Senior Lecturer in Water Systems Engineering at Imperial College London
• Dr J. Duncan Glover, from Failure Electrical LLC
• Professor José L. Torero, Director of the Center for Disaster Resilience, University of Maryland, USA
• Professor Luke Bisby, Professor of Fire and Structures at the University of Edinburgh
• Professor Niamh Nic Daeid, from the Centre for Anatomy and Human Identification, University of Dundee
• Rodney Hancox, Director, Gas Distribution Solutions Ltd.
• Steve McGuirk, former Chief Fire Officer of Greater Manchester, Cheshire and South Yorkshire, former President of the Chief Fire Officers Association, and former Lead Adviser to the Local Government Association.

Phase 1 evidence week 4

20 June 2018: Appointment of John Priestley

Architect, John Priestley, was appointed to produce a report into the architectural design of the refurbishment of Grenfell Tower. He was to examine the choice of materials, compliance with legislation and regulations, and the quality of the workmanship on the building.

He was dismissed on Friday 22 June when it was discovered that he was no longer correctly registered.

21 June 2018: Behailu Kebede's evidence: Flat 16

Behailu Kebede evidence was read out. He explained that before the refurbishment he had a lovely flat which he had lived in for twenty five years, but after, none of the residents was happy. He noted that the window had gaps around it, there were gas pipes laid in the corridors restricting their width. There were electricity surges that damaged fridges and laptops. “I had no idea that highly flammable cladding had been installed on the outside of the building.”

On the night of the fire he returned from work, and napped in the living room being woken by a beeping; the kitchen door handle was hot, looking inside there was fire behind the Hotpoint fridge-freezer, which had never been faulty. He alerted his neighbours at 12:59 and called the fire brigade who arrived and seemed confident they could extinguish the fire. Then he watched from the outside as the fire got bigger and out of control.

Since the fire he has been harassed by media and the Daily Mail, and he is living in temporary accommodation to avoid them.

His tenant, Elsa Afeworki, wrote, “It was so quick and so strong. No one could control it. It was like the way petrol catches fire. … I just don’t understand why the council would have put the cladding up on the building that they did.”

The London Fire Brigade incident logs were published. Among transcripts that arecross-examined in week five, the “operational response” reveals that more than 140 fire engines and 720 firefighters were deployed; deputy assistant commissioner, Andrew Bell, told the inquiry on Thursday that it was probably the largest deployment of breathing apparatuses ever made in the UK.

Phase 1 evidence week 5

25 June 2018: Fire brigade incident officer's evidence

Michael Dowden gave evidence. He explained he had not been trained to handle a fire of this magnitude, and did not know that flammable cladding had been used on the Tower. He had done a familiarisation visit to the tower when the cladding was close to completion in 2016. He was in charge of the fire-fighting for the first hour. He revealed that his familiarisation visit was not an inspection, and he did not check or recall checking 11 of the 13 issues on a national guideline. These meant that protocols about evacuation were not checked, or whether there were people living in the building whose command of English might obstruct their understanding of those protocols, children who might need help, elderly people and people with mobility issues. No questions had been asked about the exterior cladding, or the nature of the lifts.

He said that he had received no training in what to look for when undertaking familiarisation checks of buildings. In his visit he did not inspect any of the cladding works, or the conditions of the fire doors. He could not remember whether he went up the tower. He did not note it had a single escape route or whether there were any sprinklers.

He revealed that training had been outsourced to the private company Babcock- and was mainly done as a series of computer simulations. He was logged as having completed on one on highrise fire fighting on 23 March 2017- but cannot recall having done so.

He revealed that a routine document with essential details about the building to guide firefighters during a fire, was not created for Grenfell Tower. It would have told them of the dimensions of the building, number of flats, hydrant and dry riser locations, fire lift locations, stairwells, entrances, exits, sprinklers and the surrounding streets. The information that Dowden did print off was last updated in 2009. It said "the building had a 'stay put' policy but little else."

26 June 2018: Fire brigade incident officer's evidence

Michael Dowden continued with his evidence. He had fourteen years experience as a fire officer and under London Fire Brigade guidance he was too junior to be left in charge of the fire as it raged out of control, that he felt out of his depth and was “consumed by sensory overload”. He was the most senior officer until 1.50am, and by 1.28am he had ordered 15 fire engines to the scene. Normally he wouldn't be expected to put in charge of a six-pump fire. He didn’t know the tower was wrapped in combustible cladding and could not understand why it was “sparking and spitting” as it burned. The fire burnt though the UPVC glazing and had reached the top of the tower by 1.30am. The residents were told the policy was to stay put, though some thought that Dowden should have reversed the instruction and executed full-evacuation.

In his testimony, Dowden said that even if he had reversed the instruction, there were not the resources available to him to do so. He went in to fight a compartment fire, with 6 engines and one crew with breathing apparatus. He had was faced with a fire raging 20 storeys above the fire-floor. There were a limited number of breathing apparatuses available. The building was designed with a solitary central staircase. Its design meant water was not available above 50m. He attached engine pumps to two dry risers, (the system of pipes designed to fight a fire on a single floor) this sent 230l/min to floor 3 and floor 4. Doing this for each floor was beyond the capacity of the system.

27 June 2018: Fire brigade incident officer's evidence

Michael Dowden continued with his evidence. He said he felt helpless, and questioned whether there were not other officers in brigade who would have been better placed to fight this fire. Even when people were emerging he did not question the stay-put instruction; he had no reason to believe the fire could have spread internally outside flat 16. He ordered 25 engines to the blaze but did not have a plan on how they could be deployed. BA Crews arrived from Paddington, he ordered them to get hoses to the top floor, this didn't happen because they couldn't be sure that the stairs were still safe. The smoke was so toxic, that two inhalations rendered the victims unconscious. When a helicopter arrived it was deployed to drench the east elevation. Ladders could only reach the tenth floor and hose water up a further five.

Some of the questions he answered were repetitous- as they had been independantly asked by the victims families. He could not continue when Richard Millett QC, counsel to the inquiry asked about Jessica.

Sir Martin Moore-Bick, the inquiry chairman, praised Dowden for his three days of testimony, saying he had shown “courage and candour”. The Fire Brigades Union described the line of questioning about Fire Brigade Policy as “at times absurd” given Dowden's relatively low rank. Matt Wrack, the FBU general secretary said, “There clearly are important and difficult questions to ask but they should not be directed at those who do not have the power or authority to have altered policies, operational procedures or training,”

29 June 2018: Fire officer's Badillo's evidence: Jessica Urbano

David Badillo, who has served at North Kensington fire station for 20 years, said he met a teenager coming into the building who was distressed because her younger sister, Jessica Urbano, was alone in flat 176 on the 20th floor. He attemped to enter the building and rescue her.

The first attempt was aborted when the lift opened in floor 15 and was engulfed in black smoke. He didn't have any breathing apparatus so descended. The second time he jogged up the stairs to floor twenty and entered the flat. The door was open and it was empty- oxygen was running out so he descended. He was not aware she had fled to the top floor- or would have gone there too. Radio communications did not work on the night of the fire, he said. “They completely failed. Firefighters rely on communications to do their job properly."

He described incidents he had witnessed: use of shields to fend of falling debris. burning debris setting a fire engine alight, the noise was similar to fireworks, the fire fizzing like sparklers, the fire going sideways."It looked as though the fire was catching from the cladding”, he observed.

Phase 1 evidence week 6

2 July 2018:

Thomas Abell, drove one of the first pumps that arrived at the scene early on 14 June 2017. He wrote in a statement there was no sign of smoke or flames when he arrived. An hour later fire had spread across the face of the tower. He thought ‘This is going up like rocket fuel.’ The inquiry watched a video recorded from 01:15. Abell said that about 1.45am the ferocious flames had consumed more than half of one side of the tower; a fire in a tower block should not spread in that way, fires are normally fought from the inside and not the outside. All established firefighting techniques were not working.

Justin O’Beirne, a firefighter with 20 years experience, gave evidence of poor radio communications. He sent reports to his superiors but did not get an acknowledgement- he assumed they had heard him but they hadn't. He cannot recall hearing any radio traffic. He found the stair column strangely silent with no alarms sounding and an unbelievable amount of smoke.

3 July 2018:

Egan says the stay-put policy should have been reversed earlier. Dan Egan, a senior fire safety officer with 25 years’ experience, said he believed the tower should have been evacuated when he arrived just before 2am on 14 June 2017, Pete Wolfenden and group manager Tom Goodall, senior firefighters overseeing the response, agreed. The policy had been based on the tower’s original design. It was intended to limit fires to individual flats. But with combustible cladding the flames spread quickly, jumping 19 floors in 12 minutes. The stay-put instruction was only changed to evacuation at 2.47am.

4 July 2018:

Grenfell firefighter prepared to die when oxygen almost ran out. Christopher Scarlet reports the fire lift was jammed , how he ran out of oxygen while trying to save Jessica Urbano, and the heat in her flat, 176. He expected flashover, which is when the temperature increases and increases so everything in the room self-combusts. With no air left he asked Baudillo to escort him down. How on the ground how an officer was hit by a body jumping from a high floor, and that the stay put policy was wrong.

John O’Hanlon described the effect of carrying the body of a three year old girl, had on him. He said that it reminded him of a YouTube video of a cladding fire in Dubai, he had seen. They had had a slide show, in 2016, of that fire but no training on how to fight that type of fire. He was one of the first officers to enter the flat where the fire started. They pumped at least 240 l/min of water at the burning plastic window surround. The flames would not go out; outside of the building was '“roaring” like a burning gas main'.

Daniel Egan, a fire safety manager who was responsible for relaying information from 999 calls from people inside the tower to the firefighters said there were “heated discussions” between firefighters over whether enough was being done to save people. He was effected by not being able to get help to flat 133 on the 17th floor.

5 July 2018:

Grenfell firefighters ran out of the most basic equipment, inquiry hears. Watch manager Brian O’Keefe described how firefighters risked their lives to save people by going up the burning building without proper equipment and how radio communications had failed. He revealed the anguish of colleagues who told eight people to stay in a 14th-floor flat for their safety, four of whom died.

At one point he sent colleagues without “firefighting media ((water) and breaking-in kit because we didn’t have enough of it”; he told them to use any discarded equipment they could find on the stairs. “We had used all of our resources … I knew it was too dangerous and that their lives were in danger". For a time, there were no BA crews left to deploy. This was not controlled operation but a desperate bid to rescue people.”

Firefighters were overwhelmed by the number of calls from people inside the tower; a failure in communications meant the details from the 999 calls were being ferried in on slips of paper, under falling debris. A four man crew went to rescue a solitary man from a 15th floor flat- and discovered eight people, four of whom subsequently died. O’Keefe had to physically stop some residents from reentering the building to try to save their children. Firefighters could not see and were moving around by touch, some had given their breathing masks to the children they were helping and were abandonning kit to get out alive themselves. Firefighters were collapsing from heat, smoke and exhaustion. At around 4am and 4.30am, there was a final rush through the lobby of mainly unconscious children and teenagers.

Phase 1 evidence week 7

10 July 2018:

Daniel Meyrick, who was the watch manager at Dowgate fire station, on 14 June 2017 gave evidence. He was part of the first command unit mobilised. He said the Control Room officers were handling a large number of calls from the public but the radio link to the crews was failing. He intercepted the calls, and transferred them to paper. These were passed to the firefighters, but communication was one way, and he had no way of knowing if a rescue had been successfully made.

Phase 1 evidence week 8

14 July 2018: Jason Oliff, station manager evidence

Control was usually at Merton, but as it was unavailable, control that night was at Stratford; the TV was switched off, it was broken. “Merton always has a large-screen television switched on and I believe this is an invaluable tool in decision-making when an incident like this is unfolding,” said officer Jason Oliff, station manager at Chiswick and Feltham north-west area. He recalled that he had to advise an operator to tell a father to go back into the stair column on the 21st floor to search for his family while strongly believing he would not survive. The father died but the family were rescued; the unborn child died later.

September

On the 5 September, fire officer, Peter Johnson, a station manager from Hammersmith, claimed that the building plan was not in the fire box in the lobby hindering rescuers attempts to control the fore and rescue residents. They were aware that gas pipes and service ducts had been relocated during the cladding and refurbishment, and the floorplans of the upper storeys were different to those below. "The plans themselves would have fed into the operational plan, it has a vital part and a vital role detailing fixed installations and detailing everything within the building. It would detail the pipeline of gas, of water, where electricity was – it was vital that we needed those plans."

On the 6 September it was describe how 4 people had be directed to a smoke free flat to await rescue; and them missed due to a communication problem and subsequently perished.

Reactions

The appointment of Sir Martin Moore-Bick to lead the inquiry was questioned on 3 July by lawyers acting on behalf of the families and on 4 July by the MP for Kensington, Emma Dent Coad. They all called for him to stand down, with the local MP saying that Moore-Bick lacked "credibility" with victims, who needed "somebody we can trust." Having spoken, she said, with hundreds of those affected, "We need somebody who can do the detail but we need somebody who can actually understand human beings as well." Lord Chancellor David Lidington said Moore-Bick would lead the inquiry "with impartiality and a determination to get to the truth and see justice done".

On 25 July, at the second public meeting held by the Inquiry before finalisation of the terms of reference, various residents criticised the lack of diversity of the Inquiry panel, saying that it did not represent the community. Citing the Westminster City Council case, in which Moore-Bick allowed a local resident to be rehoused 50 miles away with no explanation, a resident said "Your very presence is an affront to this community." There were calls for Moore-Bick to recuse himself. Moore-Bick responded, "We are going to investigate and find the facts in relation to the whole course of events" leading up to the fire.

Two panel members from a child abuse inquiry raised concerns about the ability of the inquiry to be independent of the government.

Social housing

Labour Party politicians and some survivors have argued that the inquiry should include an examination of national policy in national policy towards social housing. In his letter to Theresa May proposing the Terms, which were agreed without amendment, Moore-Bick had noted that many of those affected by the fire and others had been in favour of this. He argued, however, that this would add significantly to the time required to complete his work, and that such an examination was better suited to a different kind of process and not to a judge-led inquiry. in her response, Theresa May said that the Housing Minister Alok Sharma would "personally meet and hear from as many social housing tenants as possible" both in the immediate area and further afield.

In response, Jeremy Corbyn wrote an open letter to Theresa May saying: “The fire has raised profound concerns about the way that social housing is provided and managed in this country, and I as well as many survivors worry that without a wider focus, the inquiry will fail to get fully to grips with the causes of the fire.” Corbyn also said May should “immediately set out a clear, independent and thorough process for identifying and addressing the broader failings that led to the Grenfell fire.” Matt Wrack of the Fire Brigades Union said, “Central government has created the housing and fire safety regime and central government must be held to account for any failings in it. Yet the terms of reference signed off by Theresa May appear designed to avoid this.”

Soil toxicity

Anna Stec was appointed as additional expert witness to the inquiry 19 September 2018. She had been doing independent research on the long term effects of the smoke and the fumes on the surrounding soil. She had briefed Public Health England in February that it was not sufficient to monitor large particles in the air but small particle that had landed a long distance from the tower and been absorbed into the soil. She was sufficiently concerned by her interim findings to warn Public Health England who had been monitoring the air, that the soil samples she had taken up to a mile away from the tower were hugely toxic. The so called "Grenfell Cough" suffered by survivors, near residents and firefighters indicated the presence of carcinogenic polycyclic aromatic hydrocarbons (PAC)s, and the black soot that fell, and is now in the soil probably contains asbestos. Hydrogen cyanide was also present. When this was not acted on, a synopsis of her interim report was published in the Guardian- she calls for addition soil samples to be taken by PHE and Royal Borough of Kensington and Chelsea, and the groups named to be monitored for long term effects through saliva, blood and urine tests.

KPMG

On 7 January 2018, an open letter to the Prime Minister signed by 71 academics and several politicians was published. This described concern for a possible conflict of interest of the auditors KPMG, who audited the Royal Borough of Kensington and Chelsea and companies responsible for the cladding on Grenfell Tower. This was viewed by signatories as a conflict with their neutrality on the enquiry. In response, KPMG agreed to immediately withdraw from the enquiry and waive its fees.

External links

• Grenfell Tower Inquiry Official website
• Grenfell Tower Inquiry hearing videos (YouTube)
• Grenfell Tower: What happened (BBC)
• Grenfell Tower Inquiry Daily Podcast (BBC)
• @grenfellinquiry Official Twitter account