Grenfell Tower Phase 1 report highlights and initial observations

Detailing the key findings related to the planning, preparations and actions of the London Fire Brigade


On Oct. 30, 2019, the Phase 1 report of the Grenfell Tower Inquiry was released, detailing Sir Martin Moore-Bick’s review of the deadly 2017 fire at London’s Grenfell Tower in London, England. The Phase 1 report includes four volumes, totaling 856 pages.

Phase 2 of the inquiry is one of at least four separate inquiries still currently active. Other inquiries are being conducted by the Metropolitan Police Service regarding any criminal charges; Her Majesty’s Coroner for Inner London regarding the causes of death of the 72 fire victims; and the work being done by Dame Judith Hackett to strengthen the United Kingdom’s fire and building codes, as well as professional standards for architects, engineers and certifying laboratories. And I have previously written about other inquiries related to Grenfell, including an analysis of the Interim Report findings from the Independent Review of Building Regulations and Fire Safety, with an emphasis on high-rise, high-risk residential structures.

Here we provide an initial review of the Phase 1 report, based primarily on its Executive Summary.

In this Wednesday, June 14, 2017 file photo, smoke and flames rise from the Grenfell Tower, in London. Police investigating a blaze that killed 72 people in a London tower block two years ago say no one is likely to face criminal charges until 2021. (AP Photo/Matt Dunham, File)
In this Wednesday, June 14, 2017 file photo, smoke and flames rise from the Grenfell Tower, in London. Police investigating a blaze that killed 72 people in a London tower block two years ago say no one is likely to face criminal charges until 2021. (AP Photo/Matt Dunham, File)

Grenfell Tower fire background

As background, the 24-story Grenfell Tower was completed in 1974 and refurbished in 2016. Most of the Grenfell Tower’s floors served as residential housing, with approximately 220 bedrooms.

The building is owned by the Royal Borough of Kensington and Chelsea (RBKC) and managed by RBKC Management Organization.

The Grenfell Tower did not have a fire sprinkler, fire alarm or intercom system to notify tenants of fire. While there were elevators, emergency egress was limited to one central stairwell. Fire doors appear to have been present at each floor’s lobby, but in many instances had been propped open by tenants or in some cases firefighters allowing smoke to enter a floor.

The Grenfell Tower fire was reported to the London Fire Brigade at approximately 12:54 a.m. on June 14, 2017, having originated in a fourth-floor apartment caused by a fault in a refrigerator/freezer appliance.

The fire was reported as a kitchen fire, but quickly breeched one of the apartment’s PVC window frames and ignited the combustible exterior cladding consisting of polyisocyanurate and phenolic foam held in place by an aluminum composite material rain-screen panel with polyethylene cores.

The fire had spread to the cladding and foam insulation before firefighters entered the apartment of origin at 1:14 a.m. From that point, the wind-driven fire spread through the exterior of the structure both horizontally and vertically, autoclaving into each floor primarily through the windows. Unknown to the first-arriving firefighters, the spread of the fire in this manner quickly caused the loss of compartmentation. Following their standard operating procedures (SOPs), both firefighters and 999 operators initially told occupants to remain in their apartments.

This was not the only fire that was spread through similar exterior combustible cladding, nor was it the first high-rise fire of this nature in the UK. On July 3, 2009, six residents perished in the Lakanal House fire, which began on the ninth floor of a 14-story residential building in the London Borough of Southwark.

The Grenfell Tower Phase 1 report compares these two fires in several areas of the report in light of the response by the London Fire Brigade and the subsequent changes to protocols following the Lakanal fire as to whether occupants should be told to evacuate or shelter in place. Despite the confusion on the loss of compartmentation in the Grenfell fire, 225 of the 297 occupants were rescued by firefighters or found their own way to safety.

Grenfell Tower Phase 1 report conclusions and recommendations

The Grenfell Tower Phase 1 report primary inquiry centered on the planning, preparations and actions of the London Fire Brigade (LFB), its 999 Control Room Operators (CRO), and its Command Support System (CSS) at the fire. Some, but not all, of the issues raised by Sir Martin Moore-Bick are included below:

  • Confusion at the LFB and its CRO as to whether occupants should evacuate or shelter in place. Shelter in place was part of the LFB’s high-rise SOP, but information on the loss of compartmentation was not universally known to prompt a faster switch to evacuations.
  • The LFB was unprepared to deal with the combustible cladding added during renovations in 2016 despite its knowledge of other such fires internationally in both Europe and the Middle East.
  • Incident command was transferred six times in the first two hours, and at one point two individuals believed they were the incident commander.
  • A Unified Command among the LFB, Metropolitan Police Service (MPS) and London Ambulance Service (LAS) was not established.
  • Each of the LFB, MPS and LAS independently declared the Grenfell Tower fire as a “Major Incident” at different times during the incident, but failed to coordinate with the other agencies involved.
  • Communications and information-sharing systems proved incompatible among the LFB, MPS and LAS, including a police helicopter sent aloft to stream pictures to the LFB, but its system was encrypted and subsequently could not be received by the LFB Command.
  • LFB radios used by fire crews deployed in firefighting and rescues performed poorly in the high-rise building, leaving gaps of information between fire crews and Incident Command.
  • Better communications was needed to pass critical information between the LFB Control Room and Incident Command.
  • The sheer volume of calls from occupants of the Grenfell Tower requesting assistance overwhelmed the CRO capacity to process information to the LFB crews on the scene.
  • There was a need to clearly mark the floor level numbers and other fire safety information in individual floor lobbies and the central staircase landings.

Note: Phase 2 will investigate the specific building conditions at the time of the fire. It is known that the Grenfell Tower renovations did not bring it into compliance with the Building Regulations formulated in 2010. It is believed that the Royal Borough of Kensington and Chelsea, as the owner and itself a governmental agency, had the authority to exempt itself from several fire and life safety provisions, including fire sprinklers, a central fire alarm system, and additional enclosed stairwells.

Initial observations on the Phase 1 report

While we look forward to the Phase 2 on the state and condition of the Grenfell Tower after its 2016 renovations, one would hope that the inquiry will hold the owner, the RBKC, to same level of scrutiny as it has the LFB and other responding agencies. Specifically, information is needed as to who felt the use of highly combustible foam secured with an aluminum cladding could withstand any degree of fire impingement. How was it possible that the RBKC could be the owner of a property and that they as a local government could also act to exempt themselves from such safety features as fire sprinklers, a central fire alarm system and additional stairwells for egress required in the 2010 UK building revisions? In retrospect, it clearly appears the Grenfell Tower was “built to burn.”

One must also hope that the ongoing review of fire and building codes, as well as professional standards being conducted by Dame Judith Hackett, will result in legislation strengthening both entities to avoid another devastating fire like the Grenfell Tower.

I have traveled to London many times in the past 20 years as a speaker at fire service conferences, as president of the Institution of Fire Engineers - USA Branch, and as a tourist. I have met with many LFB members, and I know them to be dedicated professionals, none of whom lack the courage or determination to deliver quality fire and rescue service to their citizens.

I also know that for the last two decades, the UK Fire Service in general has seen a movement toward austerity and efficiency (i.e., a need to do “more with less”) that has closed or consolidated many of the fire brigades serving communities while seeing an increase in responses to the changing needs of a diverse and multi-cultural population.

With 67 million people in the UK, there are now estimated to be only 33,000 career and retained (paid part-time) firefighters and approximately 3,500 fire appliances. London itself has a population approaching 9 million citizens. Compare that to United States, with a population of approximately 320 million, served by 350,000 career and approximately 800,000 volunteer firefighters, utilizing an estimated 160,000 pieces of fire and rescue apparatus. Is it any wonder that this austerity move could be a part of the LFB lack of modern communications that would have afforded a greater degree of interoperability at the Grenfell Tower or any future major incident?

Considering the size of Grenfell Tower, which was a square block in area and 24 stories tall, it is understandable that a fire of this magnitude with its rapid spread from floor to floor could momentarily overwhelm any of us. But I was most concerned with the issues raised in the Phase 1 Report regarding Incident Command (IC). 

Realistically, in assuming command of a major incident, there have always been several cardinal rules:

  • Only change ICs if it can improve the operations at the incident, not just because a higher ranking officer is on scene.
  • Any hand-off of IC requires a face-to-face meeting between the outgoing and incoming IC to ensure full situational awareness of the critical factors of the incident and your response. 
  • Unified Command among the major agencies at Grenfell, the LBF, MPS and LAS provides the availability of additional resources, the exchange of critical information and the development of a single plan of action.

Given the depth of experience in the LFB from previous incidents, such as the mass-casualty incidents from terrorist attacks on the London subway and bus system, I would have predicted that all of these factors would have been second nature to the Grenfell fire and rescue response.

Defense of actions during an “unprecedented” situation

Finally, I applaud the comments of London Fire Commissioner Dany Cotton, who defended her firefighters by saying that they had faced an “unprecedented” situation in fighting the Grenfell Tower fire. Responding to the inquiry, she stated, “We are disappointed at the criticism of individual staff members, who were placed in completely unprecedented circumstances and faced the unimaginable conditions while trying to save the lives of others.”

We all will await the outcomes of the remaining Grenfell Tower inquiries.

Stay safe!

Editor's note: What are your initial takeaways from the Phase 1 report? Share your feedback in the comments below or at editor@firerescue1.com.

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