- First day of inquiry hears that ‘stay put’ strategy failed within 30 mins
- Fire fighters leaving doors ajar may have contributed to the blaze
- Air ventilation system was not operating properly
- Poorly performing fire doors contributed to spread of blaze
Written by a leading fire safety engineer, the report said all residents should have been evacuated much earlier, after the advice to stay inside the building and wait to be rescued failed within around 30 minutes.
Dr Barbara Lane said she was “particularly concerned” by the delay after 2am, when a major incident was declared, until 2.47am before the advice was officially changed to total evacuation.
The stairwell – Grenfell Tower’s only escape route – was “smoke-logged from 1.40am onwards”, Dr Lane found, and the “stay put” advice was eventually abandoned at 2.47am.
Dr Barbara Lane’s timeline:
00.54 - first 999 call
01.15 - “The principles of ‘stay put’ can be considered to have started to fail”
01.26 - ‘Stay put’ had “substantially failed”
02.47 - ‘Stay put’ abandoned
Dr Lane, a fire safety engineer, recommended that blocks of flats should have an automatic or manual means of raising an alarm or providing voice alarm announcements, as currently it is not possible to easily communicate changes in advice.
On the night of June 14, when the fire broke out, Lane said was “not clear at this stage how the ‘all out’ message was communicated to residents who were still in the Tower”.
She added that there needs to be “serious and urgent” consideration to changing the current approach in buildings enveloped in similar material to Grenfell.
An expert report by Jose L Torero found:
- Most casualties were discovered in their own flats
- 29 had travelled to other parts of the tower
- 19 were able to reach exit stairs but travelled up instead of down
- 3 victims found in either stairs or adjacent lobby
A further report by fellow fire expert Colin Todd also released on Monday, noted: “As was clearly demonstrated in the tragic circumstances of the Lakanal House fire in 2009, it is absolutely vital that the concept of ‘stay put’ is properly explained to residents (particularly as, for some residents, it may be non-intuitive and, of course, contrasts with the fire procedures they will experience in their place of work). In particular, it is important that residents understand that the ‘stay put’ strategy does not apply if they consider themselves threatened by the fire (e.g. as the result of entry of smoke or fire to their flats.”
Intel from a report submitted by Professor Jose Torero claimed the fire service’s advice to residents to stay in their flats was only appropriate for the first phase of the fire - before the external cladding caught alight.
While the flames spread to the top of the building and began to penetrate flats on multiple floors, evacuation of residents was still possible via stairwells which smoke had not yet reached, he added. At this stage, Prof Torero said evacuation was not free from risk but “can be considered a better strategy than ‘stay put’.”
Firefighters may have also contributed to the spread of fire and smoke into the stairwell by leaving doors ajar as they fought the blaze, Dr Lane found.
She said current evidence indicates some of the stair doors “were ajar as firefighting hoses were running from the stair into the lobby.
In one case, a fire door to the stairwell was held open by a body, the report said.
“However, I currently do not know the number of doors involved, nor which specific doors, nor for how long this opening may have occurred. I cannot yet conclude whether this made a significant contribution.”
The automatic air ventilation system in the building was also not “in accordance with current statutory guidance” and there was evidence it did not operate as intended, Dr Lane wrote.
She wrote that this failure “would have materially affected the ability or willingness of occupants to escape independently through this space to the stair”. It would have also hindered the ability of firefighters to rescue many people on the tower’s upper floors.
Dr Lane’s report is one of five made available on Monday morning, all of which are examining how the fire took hold with such deadly effect.
Seventy-one people were killed during the tragedy in Kensington, west London, on June 14 last year. A further person died in January after a long battle with a pre-existing condition, having never left hospital since the fire.